Client Intake Form
Name of Client
First Name
Last Name
Marital Status
Please Select
Single
Married
Divorced
Widowed
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Estimated Annual Gross Income
Equal to or less than $20,000
$20,001 to $35,000
$35,001 to $50,000
Greater than $50,000
Household Size
Number of Children in Household
Referral Name
First Name
Last Name
Emergency Contact Information
Name
First Name
Last Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
I need help in the following self-development programs:
Career Development
Dance
Live Sound Engineering
Small Business StartUp
Business Documentation Assistance
Other Documentation Assistance
I need assistance accessing:
Food Programs
Primary Care Provider
Dentist
Social Worker
Diabetes Care Management
Hypertensive Care Management
Other Health Services
Other Enabling Services
Medical History
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Have you been convicted of drug related charges?
Yes
No
Please explain the circumstances
Are you currently taking prescription medication?
Yes
No
Prescribing Doctor's Name
First Name
Last Name
Prescribing Doctor's Phone
Format: (000) 000-0000.
Have you had any surgeries in the past 5 years?
Yes
No
Please specify:
Family history
Adopted
Alcoholism
Allergies
Asthma
ArthritisBlood Disease
CAD (Heart Attack)
Cancer
CVA (Stroke)
Depression
Developmental Delay
Diabetes
Eczema
Hearing Deficiency
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Irritable Bowel Disease
Learning Disability
Mental Illness
Tuberculosis
Obesity
Osteoarthritis
Osteoporosis
PVD
Renal Disease
Other
Mental Health History
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Therapist Name
First Name
Last Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
Submit
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