Counseling Intake Form

Counseling Intake Form
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Home Phone
Date of Birth

MonthDayYear
Date
Email
example@example.com
Pronouns: They or She/ Her or Him/He
Marital Status
Employment
Occupation
Primary Care Provider

NamePhone Number
Preferred Method of Contact

E-mailHome PhoneCell PhoneText Messaging
Are you ok if we leave a message? (Home phone, cell phone, text message)

YesNo
If yes, where is it ok to leave a voice mail, email, or text message?

Home PhoneCell PhoneText MessageEmail
Type of Counselling Seeking:

IndividualCouplesFamilySupport GroupsOther
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Alternative Phone Number
Relationship
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you or do you use drugs? (non-prescribed medication)

YesNoFormer User
Please list:
Are you currently taking prescription medication?

YesNo
Have you had any surgeries or hospitalizations in the past 5 years?

YesNo
Please specify:
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
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?

YesNo
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

MonthDayYear
Date
Signature

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Counseling Intake Form

Emergency Contact Information

Medical History

Mental Health History