In take form

Client Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Intake

MonthDayYear
Date
Thank you for completing this form. The information you provide will help us better understand your needs and create an effective treatment plan.
Malefemalenon-binaryOther
Other
EthnicityRace optional
Primary Language
SECTION 2: REASON FOR SEEKING SERVICES
What brings you to seek services today
1-3 month6 monthsone year
What do you hope to achieve from counselingtreatment
Rate the severity of your current concerns 1-5

1

2

3

4

5

1 is Worst, 5 is Best
Yesno
If yes please explain
SECTION 3: MENTAL HEALTH HISTORY
yesno
If yes please specify
yesNo
Previous therapists or psychiatrists
Previous mental health medications
Dates of treatment

MonthDayYear
Date
SECTION 4: SUBSTANCE USE HISTORY
Have you experienced any substance-related problems (e.g., legal, health,relationships)?
marijuanaprescription drugsopiodsmethaphetamineHallucinogensCocaine
If yes explain
yesno
If yes when and where
SECTION 5: MEDICAL HISTORY
Do you have any current or past medical conditions (e.g., chronic illness, surgeries)?
If yes specify
Do you experience physical symptoms related to your mental health? Like fatigue, digestive issues,or Muscle weakness?
Other
Current Medications
SECTION 6: BEHAVIORAL AND EMOTIONAL FUNCTIONING
What are some of your current life stressors?
How would you describe your mood most days?
yesno
YesNo
If yes explain
Who can you rely on for emotional support?
SECTION 7: SELF-ASSESSMENT
On a scale of 1-5 how would you rate you mental health.

1

2

3

4

5

1 is Worst, 5 is Best
On a scale of 1-5 how would you rate your physical health

1

2

3

4

5

1 is Worst, 5 is Best
On a scale of 1-5 how would you rate your current stress level

1

2

3

4

5

1 is Worst, 5 is Best
On a scale of 1-5 how would you rate the level of support in your life

1

2

3

4

5

1 is Worst, 5 is Best
What strengths do you bring to this process
What barriers might interfere with your progress
SECTION 8: CONSENT AND SIGNATURE
I acknowledge that the information provided is accurate to the best of my knowledge. I understand this information will be used to assist in developing a treatment plan and will remain confidential, except where disclosure is required by law.
Client Signature
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Should be Empty:

SECTION 4: SUBSTANCE USE HISTORY

SECTION 5: MEDICAL HISTORY

SECTION 6: BEHAVIORAL AND EMOTIONAL FUNCTIONING

SECTION 7: SELF-ASSESSMENT

SECTION 8: CONSENT AND SIGNATURE