Detailed Intake

Detailed Intake

1948 N Plaza Dr. Rapid City, SD 57702
Please fill out this questionnaire as completely as possible. Your information will be kept confidential.
Today's Date

MonthDayYear
Date
Basic Information
Name

First NameLast Name
M/F
Birth date

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at this location?
Number of times moved in last 5 years
Main Phone
Format: (000) 000-0000.
Email Address
example@example.com
Educational & Vocational
Highest grade completed
College (If attended)
Degree(s)
Vocational training
Military Service: Branch
Years served
Employer
Job Title
How long have you been at this job?
How many jobs have you had in the last 5 years?
Reasons for Leaving
Marital Data
Status
If Applicable: Spouses name
Age
# of times married
Occupation
Does your spouse know you are coming to receive counseling?
Children

Please evaluate the relationship between you and your parents while growing up. Check all that apply.

Rows	Father	Mother	Step-Father	Step-Mother
Had the greatest effect on you?
Usually did the disciplining
Was away a great deal?
You identified with the most?
You were close to?
Major conflicts with?
More dominant personality?
Abuse drugs and/or alcohol?
Physically abused you?
Was a workaholic?

How many siblings do you have?
Were you?
How many siblings does your spouse have?
Was your spouse?
How would you describe your childhood?
Health Survey
Are you presently under a physicians care?
Date of last visit

MonthDayYear
Date
Physicians name?
Personal physician if different?
For what condition(s) are you being treated?
Date of your last complete physical examination?

MonthDayYear
Date
What, if any, medications are you currently taking? (give dosage and reason for medication)
Do you have a history of drug use?
Current use?
Frequency?
Type of drugs?
Have you had a history of excessive use of alcohol?
Do you presently?
Have you been hospitalized for emotional problems?
If yes, give date(s) and reason(s)?
Have you taken medications for emotional problems?
If yes, please list?
Have you experienced any recent significant weight loss or gain?
Please list any other medical conditions.
Have you previously received counseling?
If yes, was it helpful?

If you have previously received counseling complete the following?

Rows	Dates?	With whom?	Reason(s)?	Reason for stopping?
Previously received counseling?

Rows	Have a high need for achievement?	Have a high need for approval?	Be a workaholic?
Do you have a tendency to:

Do you struggle with relationships? If yes, please explain.
What has been your exposure to pornography? Explain:
Has screen time/phone usage caused conflict in any relationships? Explain:
Summarize where you spend the most time on your phone (most utilized apps):
Are finances a recurring problem?

Other
Do you have any overwhelming fears? If yes, please explain.
Have you ever had any non-Christian religious or spiritual experiences? (cult involvement, daily horoscope, psychic experiences, etc) If yes, please explain.
Have you ever been involved in criminal activity?
List any arrests and convictions with the dates:
What has been your greatest disappointment? Please describe.
Explain briefly what you believe your problem is:
What do you want the Biblical counseling process to accomplish?
Why did you choose Christian Life Ministries? Other Comments?
Should be Empty:

Basic Information