Counseling Intake Form

Client Intake Form
As you fill out this form, please know that it will be used to better understand how we can help you. Please include any information that you think is necessary for us to be able to help you as much as we can. The basic questions are requried before any sessions. Everything else is a bonus in order to help you more.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact

MobileE-mail
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Preferred Name
Pronouns
Martial Status
Who do you live with?
Do you have children, if yes, how many?
Do you have pets, if yes, how many?
What is your current employment?
Highest level of orientation
What is your sexual orientation?
Why are you seeking help?
Have you received therapy or coaching in the past? Please share anything important about your experience or whatever you want me to know in order to help you.
Current Symptoms

Other
Have you ever had feelings or thoughts that you didn't want to live?
Do you or have you ever self harmed?
On a scale of 1 to 10, (ten being strongest) how often do you feel unhappy?

1

2

3

4

5

6

7

8

9

10

1 is Weak, 10 is Strong
List all current prescription medications and how often you take them
Current physical medical problems?
Current mental health struggles? Have you been diagnosed?
What are the mental and physical health struggles in your family?
How often do you exercise?
Average hours of sleep per night?
How often do you drink?
Do you use any substances, if yes, which ones and how often?
Do you smoke cigarettes?
What is your coping mechinism?
Please share basic information about your childhood, including siblings and the ages, and anything important about your parents.
Is there any information you want to share about your childhood/family?
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.
In the past five years, has there been any traumatic experiences in your life?
What are you hoping to achieve in this process? What are your goals?
Emergency Contact

First NameLast Name
NumberFormat: (000) 000-0000.
Click here to view and review consent forms
By signing below, I confirm I am the person in the "Name" section and that all the information entered above is true to my knowledge. I also confirm that I have recieved (by email and/or the link above), reviewed, and signed the eleven page consent packet which includes the following documents: Coach & client agreement, practice policies, informed consent for coaching general information, consent for virtual coaching sessions, and notice of privacy practices
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Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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Client Intake Form