Counseling Services Intake Form

Counseling Services Intake Form

Thank you for reaching out to us. This form helps us understand you, your child, or your family and what support you’re hoping for. There are no right or wrong answers, and you may share as much or as little as you feel comfortable. Your responses are confidential and will help us provide the best care possible.
Client Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Gender
Pronouns
Race
Religion/Spirituality
Employer
Primary Care Physician

First NameLast Name
Primary Care Physician Phone Number
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Format: (000) 000-0000.
Insurance Information
Name of Insurance Provider
Name of Policy Holder
Policy Holder Social Security Number
Policy Holder Date of Birth
Insurance Member Identification Number
Insurance Member Group Identification Number
Does you or your child have secondary coverage? (i.e., Medicaid and private insurance). If so, please provide that info below.
Please upload a copy of the front and back of you or your child's current insurance card(s).

Cancelof
Referral/Request Information
How did you hear about Born to Blossom or Elizabeth Parker, LPC?
Reason for seeking counseling at this time:
What are you hoping counseling might help with? (Check any that apply)

Other
If "Other," please briefly explain:
Please list any concerns which you are or are have been seen for:
Current Concerns/ Challenges

Please check any areas that feel relevant right now for you or your child.
Adults: Please check any concerns you're experiencing currently

Other
If "Other," please describe what you are experiencing:
Children/teens (parent-report): Please check any concerns you’re noticing for your child/teen currently

Other
If "Other," please describe what your child/teen is currently experiencing:
If "Other," please describe what your child/teen is currently experiencing:
Have you/your child ever had feelings or thoughts that you/they didn't want to live?
Do you/does your child currently feel that you/they don't want to live or of attempting suicide?
If Yes to either of the 2 above questions, how often do you/they have these thoughts?
If Yes to either of the 2 earlier questions, when was the last time you/they had thoughts of dying or attempting suicide?
On a scale of 1 to 10, (ten being strongest) how strong are thoughts of dying or attempting suicide currently:

0

1

2

3

4

5

6

7

8

9

10

0 is Weak, 10 is Strong

Rows	Yes	No
Do you/does your child have feelings of hopelessness or worthlessness?
Have you/has your child ever tried to harm or kill yourself/themselves before?
Is there anything that would stop you/your child from killing yourself/themselves?

Psychological / Therapy History

Sharing any past supports helps us understand what you or your child have already tried and what has or hasn’t been helpful. You may skip any questions or share only what feels comfortable.
Has the client received counseling, therapy, or behavioral supports before?
If Yes, which types of support?

Other
Are any supports currently ongoing?
Would you like coordination with other providers?
Was there anything you found helpful or unhelpful about past supports?
Current or Previous Therapist/Counselor, if applicable:

First NameLast Name
Current or Previous Therapist/Counselor Phone Number, if applicable:
Format: (000) 000-0000.
Medical / Medication Information

This helps your counselor understand any medications or health factors that may affect mood, focus, or daily functioning.
Date of last physical exam/wellness check:

MonthDayYear
Date
Does the child or adult have any history of infectious diseases or other medical diagnoses we should know about?
Current medical problems/issues, if any:
Past medical problems, non-psychiatric hospitalizations, and/or surgeries:
Do you have any allergies? (If yes, please list them)
List all current prescription medications and how often you take them (excluding psychiatric medications):
If you have prescription medications you are currently taking, please list the name(s) of the doctor(s) who have prescribed them:
Psychiatric History

This helps us understand past levels of support so we can plan care thoughtfully.
Have you ever been treated as an outpatient for mental health concerns?
If yes, please describe when, by whom, and nature of treatment:
Have you ever been treated as an inpatient at a psychiatric facility?
If yes, please describe when, by whom, and nature of treatment:
Mental Health-Related Medications

This section helps us understand any medications that may affect mood, sleep, focus, emotions, or behavior. Sharing this information is optional, and you may include only what feels comfortable.
Are you or your child currently taking any medications related to mental health, mood, attention, sleep, or behavior?
If yes, please list all current mental health-related prescription medications and how often you/your child take(s) them:
Who currently manages or prescribes these medications?
Has the client taken mental health-related medications in the past?
If yes, please list the medication(s) that were taken, what was helpful or unhelpful about the medication(s), and the reason you stopped the medication (if known):
Is there anything else you'd like us to know about your/your child's psychiatric medications?

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Rows	Have you ever taken it?	Dates	Dosage	Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)

Family Mental Health History

Many people have family members with a range of emotional or mental health experiences. Sharing this information is optional and simply helps us get a fuller picture.
Has anyone in your family been diagnosed with or treated for:

Other
Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment?
Exercise Level

This section helps us understand how movement fits into daily life, as it can sometimes affect mood, energy, and stress. You may share only what feels comfortable.
Adults: Do you exercise regularly?
How much time each day do you exercise?
Substance Use History

This section helps us understand any use of substances that may affect mood, behavior, safety, or overall well-being. There is no judgment about substance use. Sharing this information is optional and helps us provide the most supportive care.
Check if you have ever tried the following or are you currently using the following:

Other
How many caffeinated beverages do you drink a day?
Tobacco Use History

This section helps us understand any use of tobacco or nicotine products, as these can sometimes affect mood, health, or stress. There is no judgment about tobacco use. Sharing this information is optional and helps us provide the most supportive care.
Have you ever smoked cigarettes?
How many packs per day?
How many years?
Family Background and Childhood History:

Everyone’s family and childhood experiences are different. This section is optional and simply helps us get a fuller picture to support care.
Were you adopted?
For children/teens: Was the child adopted?
Where did you grow up?
Did your parents divorce?
Do you have siblings, and if so, how many?
Some people have experienced difficult or harmful events during childhood, and others have not. This question is optional and meant to help your counselor understand your early experiences so we can provide the best support. You may share as much or as little as feels comfortable, and you can skip this question entirely. Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where, and by whom.
For children/teens (parent-report): To the best of your knowledge, has your child/teen ever experienced harm, neglect, or exploitation within their family or caregiving environment? If yes, please describe when, where, and by whom.
Educational History

This helps us understand learning experiences and current supports.
What is your/your child's highest grade completed?
Children/teens: If currently in school, what is the name of the school? This is only so that your counselor has shared knowledge of the child/teen's current educational supports.
Children/teens: If currently in school, what is the name of their teacher? This is only so that your counselor has shared knowledge of the child/teen's current educational supports.
Is there anything you would like us to know about the child/teen or adult's educational or school history?
Personal History

People have many different life situations, and there are no right or wrong answers here. Sharing this information is optional and helps us better understand your daily life and support system.
Are you currently:

Other
Are you currently:

Other
Do you have any children?

Other
Please list ages and gender:
Have you ever been arrested? There are no judgments about arrests.
Additional information
Emergency Contact

First NameLast Name
Phone Number
Format: (000) 000-0000.
Date

MonthDayYear
Date
Signature
Guardian Signature (if under age 18)
Should be Empty:

Counseling Services Intake Form

Client Information

Insurance Information

Referral/Request Information

Current Concerns/ Challenges

Psychological / Therapy History

Medical / Medication Information

Psychiatric History

Mental Health-Related Medications

Family Mental Health History

Exercise Level

Substance Use History

Tobacco Use History

Family Background and Childhood History:

Educational History

Personal History