Counseling Intake Form
Patient Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Pronouns: They or She/ Her or Him/He
Marital Status
Please Select
Single
Married
Divorced
Widowed
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Occupation
Primary Care Provider
Name
Phone Number
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Text Messaging
Are you ok if we leave a message? (Home phone, cell phone, text message)
Yes
No
If yes, where is it ok to leave a voice mail, email, or text message?
Home Phone
Cell Phone
Text Message
Email
Type of Counselling Seeking:
Individual
Couples
Family
Support Groups
Other
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Alternative Phone Number
Format: (000) 000-0000.
Relationship
Medical History
Please check all the apply
None
Allergies
Anemia
Angina
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Benign Prostatic
Hypertrophy
Blood Clots
Cancer
Cerebrovascular Accident
Cronary Artery Disease
COPD (Emphysema)
Crohn's Disease
Depression
Diabetes
Gallbladder Disease
GERD (Reflux)
Hepatitis C
Hyperlipidemia
Hypertension
Irritable Bowel Disease
Liver Disease
Migraine Headaches
Myocardial Infarction
Osteoarthritis
Osteoporosis
Peptic Ulcer Disease
Renal Disease
Seizure Disorder
Thyroid Disease
Other
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Have you or do you use drugs? (non-prescribed medication)
Yes
No
Former User
Please list:
Are you currently taking prescription medication?
Yes
No
Have you had any surgeries or hospitalizations in the past 5 years?
Yes
No
Please specify:
Family history
Adopted
Alcoholism
Allergies
Asthma
ArthritisBlood Disease
CAD (Heart Attack)
Cancer
CVA (Stroke)
Depression
Developmental Delay
Diabetes
Eczema
Hearing Deficiency
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Irritable Bowel Disease
Learning Disability
Mental Illness
Tuberculosis
Obesity
Osteoarthritis
Osteoporosis
PVD
Renal Disease
Other
Mental Health History
Why you are seeking counselling?
What do you expect / hope from counseling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Average hours of sleep per night
Please describe any other experiences you have had that you feel is relevant.
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: