Confidential Intake Information
Today's Date
*
-
Month
-
Day
Year
Date
General Information
Name
*
First Name
Middle Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary/Gender-fluid
Other
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cell Phone
Format: (000) 000-0000.
Ok to leave voicemail or text?
Yes
No
Home Phone
Format: (000) 000-0000.
Ok to leave voicemail at home?
Yes
No
Work Phone
Format: (000) 000-0000.
Ok to leave voicemail at work?
Yes
No
Email
example@example.com
Ok to email?
Yes
No
Emergency Contact
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Employment
Current Employer:
Length of time employed:
If currently unemployed, how long?
Have you ever served in the military?
Yes
No
If yes, please list branch, rank, and current status (active, discharged, retired)
If deployed, please list dates:
Educational/Training Background
Educational Level:
Please Select
High School Diploma
GED
Vocational/Trade School Certificate
Associate Degree
Bachelors Degree
Masters Degree
Doctorate Degree
Other
Major or name of program:
Back
Next
Family Information
Are you currently in a relationship?
Yes
No
If yes, please list status:
Name of person:
Prefix
First Name
Last Name
Length of time together:
Number of marriages:
Number of divorces:
If widowed, your age at death of spouse:
Do you have children?
Yes
No
Child 1:
First Name
Last Name
Age
Lives with you?
Yes
No
Child 2:
First Name
Last Name
Age
Lives with you?
Yes
No
Child 3:
First Name
Last Name
Age
Lives with you?
Yes
No
Child 4:
First Name
Last Name
Age
Lives with you?
Yes
No
Other persons living in your household and your relationship to them:
Back
Next
Medical History
Name of Primary Physician:
Phone Number
Format: (000) 000-0000.
Please list any prescription medications you are currently taking:
Rows
Medication
Dosage
1
2
3
4
5
6
7
8
9
10
Please list any over the counter medications, vitamins, or herbal supplements you are using:
Please answer the following questions using:
5-Excellent, 4-Good, 3-Average, 2-Poor, 1-Failing
How would you currently rate your physical health:
Please Select
5-Excellent
4-Good
3-Average
2-Poor
1-Failing
How would you currently rate your mental health:
Please Select
5-Excellent
4-Good
3-Average
2-Poor
1-Failing
How would you currently rate your spiritual health:
Please Select
5-Excellent
4-Good
3-Average
2-Poor
1-Failing
N/A
If does not apply, please use N/A.
Do you have, or have you had in the past, any of the following? Check all that apply.
Asthma
Allergies
Heart Disease
Arthritis
Headaches
Fibromyalgia
Sleep Disorder
Tuberculosis
High Blood Pressure
Immune System Problems
Epilepsy
Brain Injury
Vision Problems
Hearing Problems
Sexually Transmitted Disease
Seizures
Diabetes
Cancer
Chronic Fatigue Syndrome
Breathing Problems
Multiple Sclerosis
Thyroid Disorder
Urinary Disorder
Digestive Disorders
Blood Disorders
Weight Problems
Surgery
Miscarriage
Abortion
Pregnancy
Asthma - Date of Onset:
Allergies - Date of Onset:
Heart Disease - Date of Onset:
Arthritis - Date of Onset:
Headaches - Date of Onset:
Fibromyalgia - Date of Onset:
Sleep Disorder - Date of Onset:
Tuberculosis - Date of Onset:
High Blood Pressure - Date of Onset:
Immune System Problems - Date of Onset:
Epilepsy - Date of Onset:
Brain Injury - Date of Onset:
Vision Problems - Date of Onset:
Hearing Problems - Date of Onset:
Sexually Transmitted Disease - Date of Onset:
Seizures - Date of Onset:
Diabetes - Date of Onset:
Cancer - Date of Onset:
Chronic Fatigue Syndrome - Date of Onset:
Breathing Problems - Date of Onset:
Multiple Sclerosis - Date of Onset:
Thyroid Disorder - Date of Onset:
Urinary Disorder - Date of Onset:
Digestive Disorders - Date of Onset:
Blood Disorders - Date of Onset:
Weight Problems - Date of Onset:
Surgery - Date of Onset:
Miscarriage - # & Date(s)
Abortion - # & Date(s)
Pregnancy - # & Date(s)
Other illnesses, please explain:
Substance Use
Please indicate substances currently used (over the past six months), how much at one time, how many times per day/week, age of first use, past use history, and length of time used:
Rows
Current?
Amount
Frequency
Age
Past Use
Length
Caffeine
Yes
No
Alcohol
Yes
No
Diet Pills
Yes
No
Tobacco
Yes
No
Marijuana
Yes
No
Ecstacy
Yes
No
Street Drugs
Yes
No
Cocaine/Crack
Yes
No
Heroin
Yes
No
Meth
Yes
No
PCP/LSD
Yes
No
Pain Killers
Yes
No
Steroids
Yes
No
Tranquilizers
Yes
No
Sleeping Pills
Yes
No
Have you ever believed your substance use was a problem?
Yes
No
Has anyone ever told you your substance use was a problem?
Yes
No
Have you ever had withdrawal symptoms when trying to stop using?
Yes
No
Have you ever had problems with work, relationships, or the law due to your substance use?
Yes
No
If yes, please describe:
Have you ever participated in drug and/or alcohol treatment?
Yes
No
If yes, please list type, length, dates, and age at time of services:
Do you currently or have you participated in Alcoholics or Narcotics Anonymous?
Yes
No
If yes, please list length of time sober and number of meetings you attend per week:
Back
Next
Mental Health Information
Please check any of the following symptoms or complaints that apply to your situation:
Sad mood
Low energy/chronic fatigue
Hopelessness
Worthlessness
Guilt
Crying spells
Decreased motivation/apathy
Loss of interest in usual activities
Loss of concentration
Irritability
Hyperactivity
Impulsiveness
Increased sexual interest
Loss, decrease or increase of appetite
Social isolation/withdrawal
Difficulty falling asleep/staying asleep
Excessive sleeping
Early morning awakenings
Racing thoughts
Elevated mood
Excessive worrying or anxious feelings
Panic attacks
Fear of situations
Fear of leaving home
Fear of embarrassing oneself in public
Intruding of repetitive or uncomfortable thoughts
Being orderly or a perfectionist
Rebelliousness or defiant behaviors
Excessive anger or aggressiveness
Spitefulness or vindictiveness
Difficulty trusting others
Binging/purging or restricting food
Victim of physical abuse
Victim of sexual abuse
Victim of emotional abuse
Have you ever or are you currently engaging in self-harm?
Currently
Past
Have you ever or are you currently contemplating harming another person?
Currently
Past
Have you ever or are you currently contemplating suicide?
Currently
Past
Have you ever attempted suicide?
Yes
No
If yes, please list date(s), method(s), and your age at the time of attempt:
Has anyone in your family ever attempted suicide?
Yes
No
If yes, please list relationship:
Has anyone in your family ever completed suicide?
Yes
No
If yes, please list relationship:
Are you currently receiving mental health services?
Yes
No
If yes, please list name and address of practitioner and type of services:
Have you ever been diagnosed with a mental illness?
Yes
No
If yes, please list illness(es) and date(s) diagnosed:
Have you ever been hospitalized for mental health concerns?
Yes
No
If yes, please list dates and length of stay:
Date of most recent illness/symptom or issue for which you are seeking counseling:
-
Month
-
Day
Year
Date
Have you previously had the same or similar symptom(s)?
Yes
No
If yes, give first date:
-
Month
-
Day
Year
Date
Back
Next
Patient's Family History Information
Did your parents ever divorce?
Yes
No
If yes, your age at time of divorce:
Were you adopted?
Yes
No
If yes, at what age?
Were you ever in foster care or residential care?
Yes
No
If yes, please list age and living situation:
Mother's current age:
If deceased, her age at death:
Your age upon her death:
Father's current age:
If deceased, his age at death:
Your age upon his death:
Do you have siblings?
Yes
No
If yes, please list names, ages, and relationship:
Rows
Name of Sibling
Age
Relationship
1
Biological
1/2
Step
2
Biological
1/2
Step
3
Biological
1/2
Step
4
Biological
1/2
Step
5
Biological
1/2
Step
6
Biological
1/2
Step
7
Biological
1/2
Step
8
Biological
1/2
Step
9
Biological
1/2
Step
10
Biological
1/2
Step
Patient's Family Mental Health Background
Is there any history of the following in the client's family? (Family includes parents, siblings, paternal or maternal grandparents, aunts, uncles, and/or cousins)
Rows
Yes
No
Family member
Depression
Anxiety
Bi-polar
Schizophrenia
Drug Abuse
Alcoholism
Other
Please indicate if a member of your immediate family experienced any of the following:
Emotional Abuse
Legal Problems
Physical Abuse
Frequent/Multiple Moves
Sexual Abuse
Homelessness
Domestic Violence
Financial Problems
Neglect
Lived in another country
Military member
Serious illness
Accident or Injury
Other
Back
Next
Legal Information
Have you ever been the victim of a crime?
Yes
No
If yes, please list date and briefly describe:
Are you currently involved in a divorce or child custody proceedings?
Yes
No
If yes, please explain:
Have you ever been convicted of a misdemeanor or felony?
Yes
No
If yes, please explain:
Are you currently involved in any legal actions?
Yes
No
If so, please explain:
Is there a recent life crisis that has prompted you to seek counseling at this time?
Yes
No
If yes, please describe:
I further acknowledge that I am voluntarily consenting to counseling and that no guarantees have been made as to the results of counseling.
*
Date
-
Month
-
Day
Year
Date
Print Form
Submit
Should be Empty: