Getting Started with The Rusted Rock

Getting Started with The Rusted Rock

Please complete this intake form so The Rusted Rock can better understand your needs, background, supports, safety considerations, and communication preferences before services begin.
Intake & Contact Information
Name

First NameLast Name
Preferred Name/Nickname
Pronouns
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email Address
example@example.com
Relationship to Emergency Contact
Referral, Motivation, and Background
How did you hear about The Rusted Rock?
What motivated you to seek support now?
Have you previously worked with a support professional?
If yes, what was helpful or unhelpful about those experiences?
Current Life Circumstances
Current overall quality of life
Areas creating the most stress, imbalance, or difficulty

Other
If Other, please describe.
Major life changes, stressors, or transitions happening now
Living situation - Please describe.
Wellness, Recovery, and Supports
What is important to you?
Mental Wellness, Recovery, and Personal Growth Journey - Please describe history.
Spiritual, Faith-Based, Mindfulness, or Grounding Practices - Please describe.
Are recovery or substance use challenges part of your story?
If yes, please explain.
Strengths - Please list.
Supports Currently in Your Life (Please list at least three and relationship to you)
Providers and Support Network
Which providers or support services are you currently working with?

Other
If Other, please describe
Important information about your support system, providers, or relationships
Consistency, Routine, and Daily Functioning
Areas hardest to stay consistent with

Other
If Other, please describe
Coping skills, routines, or practices that are currently helpful
What does a typical week look like?
Consistency with maintaining routine healthcare appointments
Current sleep and overall self-care habits
Additional comments regarding sleep and overall self-care habits
Satisfaction with work, school, or daily responsibilities
Employment/Education status
Safety, Triggers, and Emotional Support
Have you had any recent mental health crises, psychiatric hospitalizations, overnight psychiatric admissions, or other safety concerns we should know about before services begin?
If yes, please explain
Are you currently experiencing any thoughts of harming yourself or others?
Triggers, sensitivities, or topics to be aware of:
What would help you feel emotionally safe, supported, and understood while working together?
What are your main goals for working with The Rusted Rock? (We will work on these through monthly Implementation Planning)
What tends to get in the way of consistency, progress, or feeling supported?
What does it look like when you feel genuinely supported?
Communication, Availability, and Session Preferences
Preferred communication outside of sessions
Permission to leave voicemail messages
Communication preferences or support styles that feel most helpful
General availability
Specific days if needed
Preferred session settings
Signature
Date

MonthDayYear
Should be Empty:

Getting Started with The Rusted Rock

Intake & Contact Information

Referral, Motivation, and Background

Current Life Circumstances

Wellness, Recovery, and Supports

Providers and Support Network

Consistency, Routine, and Daily Functioning

Safety, Triggers, and Emotional Support

Communication, Availability, and Session Preferences