Mindful Steps Adult Intake Forms

Counseling type

Current therapist or counselor

Therapist or counselor phone

Please enter a valid phone number.Format: (000) 000-0000.

Reasons for seeking help

Treatment goals

Current symptoms

Ever had thoughts of not wanting to live

Currently feel like you do not want to live

Other current symptoms not listed

Frequency of thoughts

Last time thoughts of dying occurred

Recent triggering events

Current desire to die or harm yourself (1-10)

Ever thought about how you would die or harm yourself

Method readily available

Time has been planned

Anything that would make it better

Anything that would stop you from dying or harming yourself

If yes, when

Hopeless or worthless feelings

Prior attempts to kill or harm yourself

Access to guns or firearms

If yes, what would stop you

Personal or family medical history important to know

If yes, explain access to guns or firearms

Outpatient psychiatric treatment history

If yes, explain medical history

Psychiatric hospitalization history

If yes, describe reason, dates, and provider

Prior psychiatric medications

If yes, describe reason, when, where, and dates

Family psychiatric history

If yes, list medications and helpfulness

Alcohol or drug treatment history

If yes, list family member and problem

Abuse or neglect history

If yes, specify substances, where, and when

If yes, list type, when, where, and by whom

Current occupational status

If currently working, how long in present position

Current relationship status

Currently in a relationship

How long in current marital or partner status

Prior marriages

If yes, how long current relationship has lasted

If so, number of prior marriages

Children

If so, how long

If so, number of children

Prior arrests

Children's ages and genders

Pending legal problems

If yes, what for

Religion or spiritual group involvement

If yes, describe legal problems

If yes, level of involvement

Involvement is more helpful or stressful

If stressful, explain

Anything else you want the clinician to know

Consent to Treatment
I voluntarily consent to counseling services with Mindful Steps. Therapy involves collaboration, honest participation, and discussion of goals and progress. Benefits are possible, but outcomes are not guaranteed; discussing difficult experiences may cause discomfort. I may ask questions about treatment, alternatives, risks, and benefits before consenting.

Right to Terminate Treatment
I may stop treatment or withdraw consent at any time. My therapist may end treatment when clinically appropriate, when my needs are outside their scope, or when continued services cannot reasonably be provided. When appropriate, the therapist will discuss closure, provide notice, and assist with referrals or transition of care.

Confidentiality and Its Limits
My communications and records are confidential, subject to authorized releases and disclosures permitted or required by law, including mandated abuse or neglect reporting, serious safety concerns, lawful court requirements, and permitted treatment, payment, and healthcare operations. Confidentiality is not absolute. I may ask about privacy practices and access to my records.

Financial Responsibility
Insurance verification is not a guarantee of payment. I am responsible for applicable copayments, coinsurance, deductibles, and session charges not covered by insurance, including coverage lapses or termination, only to the extent permitted by law and the applicable insurance/provider agreement. I will promptly report insurance changes. Self-pay charges will be explained before services. I may contact Mindful Steps with billing questions.

Telehealth Consent
Telehealth uses electronic audio and/or video communication. Participation is voluntary and either I or my therapist may stop telehealth if it is unsuitable and discuss alternatives. Privacy and technical risks include interruptions and unauthorized access; security cannot be guaranteed. I will use a private setting, confirm my current physical location and emergency contact at each session, and agree on a phone backup if the connection fails. Sessions will not be recorded without mutual consent. My therapist may contact local emergency services or my emergency contact if needed. Usual confidentiality and financial policies apply.

PCL-5 PTSD Checklist

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then select the response that best indicates how much you have been bothered by that problem in the past month.

Repeated, disturbing, and unwanted memories of the stressful experience?

Repeated, disturbing dreams of the stressful experience?

Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

Feeling very upset when something reminded you of the stressful experience?

Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

Avoiding memories, thoughts, or feelings related to the stressful experience?

Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

Trouble remembering important parts of the stressful experience?

Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

Blaming yourself or someone else for the stressful experience or what happened after it?

Having strong negative feelings such as fear, horror, anger, guilt, or shame?

Loss of interest in activities that you used to enjoy?

Feeling distant or cut off from other people?

Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

Irritable behavior, angry outbursts, or acting aggressively?

Taking too many risks or doing things that could cause you harm?

Being "superalert" or watchful or on guard?

Feeling jumpy or easily startled?

Having difficulty concentrating?

Trouble falling or staying asleep?

Release of Information Consent

Name and Title of Person/Agency Receiving Information

Address of Person/Agency Receiving Information (include ZIP code)

Telephone Number

Please enter a valid phone number.Format: (000) 000-0000.

Information That May Be Released

Other Information to Be Released at Client's Request

Need or Purpose for Exchange and Disclosure

Client Signature

First NameLast Name

Date

Please provide your current insurance information exactly as shown on your insurance card. Upload clear photos of the front and back of the card. If you do not have insurance, contact the office for assistance.

Name on Insurance Card

First NameLast Name

Member ID

Insurance Company

Group ID

Provider Services Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Take Photo

Partner's Name

First NameMiddle NameLast Name

Relationship Status

Length of Time in Current Relationship

Overall Level of Concern About the Primary Reason for Counseling

Frequency of the Primary Concern

What do you hope to accomplish through counseling?

What have you already done to deal with the difficulties?

Biggest strengths as a couple

Current Level of Relationship Happiness

Personal suggestion to improve the relationship

Prior couples counseling for these problems

If yes, when/where/by whom

If yes, length of treatment

If yes, what problems were treated?

Outcome of prior couples counseling

Whether either partner has been in individual counseling before

If so, brief summary of concerns addressed

Whether either partner drinks or takes drugs to intoxication

If yes, who/how often/what substances

Whether either partner used violence, restraint, or injury

If yes, who/how often/what happened

Whether either has threatened to separate or divorce

If yes, who

If married, whether either consulted a lawyer about divorce

If yes, who

Whether either partner has withdrawn from the relationship

If yes, which partner

Number of times sexual relations occurred in the last month

How enjoyable is the sexual relationship?

Satisfaction with frequency of sexual relations

Current overall stress level

Current relationship stress level

Top three concerns in the relationship, ranked by significance

Pivotal/significant events in the relationship

Couples counseling treatment goals

Additional helpful information

Couples Informed Consent

GAD-7

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it's hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

Clinician use only — total score

If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed. Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead or of hurting yourself in some way

Clinician use only — total score

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Client Name

First NameMiddle NameLast Name

Client Initials

Date of Birth

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Client Signature

Mindful Steps Adult Intake Forms

Adult Intake Form

PCL-5 PTSD Checklist

Consent for Release and Exchange of Confidential Information

Insurance Information

Couples Counseling Initial Intake Form

GAD-7

PHQ-9

Telehealth Treatment Consent