GO AND GROW COUNSELING CLIENT INTAKE FORM
Name
First Name
Last Name
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which one do you prefer to be contacted?
Email
Phone
Other
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Other
Emergency Contact
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referred By
Insurance Information
Primary Insurance Provider Name and Subscriber Number
Policy Holder Name
First Name
Last Name
Policy Holder Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Treatment Information
Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services?
If yes, please list
Please provide the name, address and telephone number for your primary care physician
History
How is your physical health at the present time?
Are you on any medication for physical/medical issues? If yes, please list:
Are you having any problems with your sleep habits? If yes, check those that apply:
Are there any changes or difficulties with your eating habits?
Have you experienced a weight change in the last two months?
Do you exercise regularly? If yes, list weekly frequency and how many minutes/hours per session:
Do you consume alcohol regularly?
In one month, how many times do you have four or more drinks in a 24-hour period?
Do you engage in recreational drug use? If so, how often?
Do you engage in recreational drug use? If so, which drug and how often?
Are you currently in a romantic relationship?
Relationships & Behaviors
Are you currently in a romantic relationship?
Quick Check: Check issues below that apply to you.
Depressed mood
Anxiety
Relationship issues
Excessive worry
Traumatic event
Have you felt depressed recently? If yes, for how long?
Have you had any suicidal thoughts recently? If yes, how often?
Have you ever had suicidal thoughts in your past? If yes, how long ago?
How often did you have these thoughts in the past?
Do you practice a religion? If yes, what is your faith?
Are you currently employed?
If yes, who is your employer?
What is your position?
Are you happy in your current position?
Does your work make you stressed?
List your strengths and what you like most about yourself:
List areas you feel you need to develop:
What are some ways you currently cope with life obstacles and stress?
What are your goals for therapy/what would you like to accomplish?
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Submit
Should be Empty: