Mindful Steps Adult Intake Forms
Complete the adult and couples intake packet, screening tools, insurance information, consent forms, and telehealth acknowledgment. All questions are blank and editable; policies and notices remain included as provided in the PDF.
Adult Intake Form
Counseling type
Individual
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
Depressed mood
Anxiety
Panic attacks
Sleep problems
Appetite changes
Low energy
Irritability
Difficulty concentrating
Social withdrawal
Mood swings
Loss of interest
Other
Ever had thoughts of not wanting to live
Yes
No
Currently feel like you do not want to live
Yes
No
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
Yes
No
Method readily available
Yes
No
Time has been planned
Yes
No
Anything that would make it better
Anything that would stop you from dying or harming yourself
Yes
No
If yes, when
Hopeless or worthless feelings
Yes
No
Prior attempts to kill or harm yourself
Yes
No
Access to guns or firearms
Yes
No
If yes, what would stop you
Personal or family medical history important to know
Yes
No
If yes, explain access to guns or firearms
Outpatient psychiatric treatment history
Yes
No
If yes, explain medical history
Psychiatric hospitalization history
Yes
No
If yes, describe reason, dates, and provider
Prior psychiatric medications
Yes
No
If yes, describe reason, when, where, and dates
Family psychiatric history
Yes
No
If yes, list medications and helpfulness
Alcohol or drug treatment history
Yes
No
If yes, list family member and problem
Abuse or neglect history
Yes
No
If yes, specify substances, where, and when
If yes, list type, when, where, and by whom
Current occupational status
Employed full-time
Employed part-time
Student
Unemployed
Retired
Homemaker
Disabled
Other
If currently working, how long in present position
Current relationship status
Single
Married
Separated
Divorced
Widowed
Partnered
Other
Currently in a relationship
Yes
No
How long in current marital or partner status
Prior marriages
Yes
No
If yes, how long current relationship has lasted
If so, number of prior marriages
If so, how long
Children
Yes
No
If so, number of children
Prior arrests
Yes
No
Children's ages and genders
Pending legal problems
Yes
No
If yes, what for
Religion or spiritual group involvement
Yes
No
If yes, describe legal problems
If yes, level of involvement
Involvement is more helpful or stressful
Please Select
More helpful
More stressful
Both equally
Not sure
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.
Insurance Information
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 Name
Last Name
Member ID
Insurance Company
Group ID
Provider Services Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Take Photo
Take Photo
Client Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Initials
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Client Signature
*
Submit
Submit
Should be Empty: