Adult Counseling Referral & Intake Form
Client Demographics
Name
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Gender (optional):
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Preferred Method of Contact:
Email
Phone
Text
Insurance Information
Insurance Name:
Insurance Policy / Member ID:
Self-Pay / Sliding Scale Inquiry
Referring Provider (if applicable)
Provider / Agency Name:
Contact Information:
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Primary Reason for Seeking Counseling Services (check all that apply)
Primary Reason for Seeking Counseling Services (check all that apply)
Anxiety or excessive worry
Depression or persistent sadness
Stress or burnout
Life transitions
Relationship or marital concerns
Grief or loss
Trauma or past experiences
Anger or emotional regulation concerns
Self-esteem or identity concerns
Work-related concerns
Parenting or family concerns
Sleep difficulties
Other
Brief Description of Current Concerns
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Safety Concerns
Have you experienced thoughts of harming yourself?
Yes
No
Have you experienced thoughts of harming others?
Yes
No
Are there any current safety concerns we should be aware of?
Yes
No
If yes, please elaborate:
Requested Services
Individual Counseling
Couples / Relationship Counseling
Family Counseling
Career Counseling
Trauma-Informed Therapy
Unsure / Seeking Guidance
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Current Services and Treatment History
Have you ever received counseling or mental health services before?
Yes
No
Are you currently receiving any services (therapy, medication management, psychiatry, etc.)?
Yes
No
If yes, please list:
Strengths and Hobbies
Consent and Acknowledgement
I confirm that the information provided is accurate to the best of my ability.
I understand that I may be contacted for additional information.
Client Signature (print name):
Date:
-
Month
-
Day
Year
Date
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Should be Empty: