New Client Intake Form (Counselling Therapy)

New Client Intake Form

Counselling Therapy
Personal Information
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
Ethnicity
Marital Status
Email
example@example.com
Employment
Home Phone
Cell Phone
Preferred Method of Contact

E-mailHome PhoneCell Phone
Who do you live with?
How did you know about us:

Health-care professionalFriend/familySocial MediaOther
Preferred Language:

EnglishArabicBoth
Billing Information

For therapy sessions
Do you need financial assistance?

YesNo
Insurance type:

MSI onlyIFHPThird-partyOther
Reasons for Seeking Help
What are the reasons for your visit today?
How intense is your emotional distress?

0 (not at all)12345678910 (completely can't function)
To what degree do your problems affect your ability to perform at work, home, and in your relationships with others?

0 (not at all)12345678910 (completely can't function)
Average hours of sleep per night
Medical History
Name of your Family Doctor:
Please write N/A if you have none
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
Are you currently taking prescription medication?

YesNo
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
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
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Therapist Name

First NameLast Name
Therapist Location
if applicable
Have you been diagnosed with any psychiatric or mental health problems?

YesNo
Please specify diagnoses, if any
Have you experienced a recent loss of any of the following:

HomeRelativeJobOther
Are you having suicidal thoughts right now, or have you had suicidal thoughts within the past month?

YesNo
Therapy Goals
What motivated you to come here today?
What are your goals for counselling?
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
**All information shared in this intake form follow the confidentiality agreement terms.
Date

MonthDayYear
Date
Signature

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New Client Intake Form

Personal Information

Billing Information

Reasons for Seeking Help

Medical History

Mental Health History

Therapy Goals