Counselling Intake Form

Counselling Intake Form

Private Paying Clients
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Date of Birth*

DayMonthYear
Date
Marital Status
Email*
example@example.com
Employment
Primary Care Provider
Referral Name

First NameLast Name
Preferred Session Format
Mobile Phone
Alternative Phone Number
Preferred Method of Contact

E-mailMobile PhoneAlternative Phone
Emergency Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Phone Number*
Relationship*
History
What concerns or goals would you like support with? (e.g. anxiety, family issues, emotional regulation, trauma)
Has the person attending counselling seen a counsellor, psychologist or other mental health professional in the past? If so, please provide details below.
What do you expect from this counselling?
Is there anything you'd like your counsellor to know before your first session?
Will anyone else be present or nearby during your sessions? If yes, who?
Medical History
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
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
Are you currently taking prescription medication?

YesNo
Medications currently in use:
Are there any known safety concerns or risks (e.g. history of aggression, current legal matters) If so, please describe briefly.
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
*Your signature below indicates that the information you have provided above is truthful.
Date

DayMonthYear
Date
Signature

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Counselling Intake Form

Emergency Contact Information

History

Medical History