INTAKE FORM
Holistic Life Counseling, LLC Ramey Wood Rascher, MA, LMHC, LPC
Reason for Services
In your own words, what issues/concerns have brought you to counseling/coaching at this time (problems, symptoms, length, duration, severity, etc)?_
What changes would you like to make, and how do you think this process can help you make these changes?
Treatment History
Have you ever received counseling or coaching services in the past? If so, please describe when, where, and by whom. Also, please describe the outcomes of treatment (was it helpful?).
Have you ever been given a mental health diagnosis in the past from a mental health professional?
Yes
No 2
If yes, as you understand it, what is/was that diagnosis?
Have you or any members of your family had problems with:
Drugs
Alcohol
Depression
Anxiety
Other mental illness
Diabetes
Epilepsy
Please explain
Medical History
Do you have a history of any significant illness or medical issues? If so, please describe.
Please list any medications and doses you are currently taking (include OTC drugs)
Describe any current medical or physical issues (sleep disturbances, loss of or increased appetite, current medications, illnesses, injuries, etc.).
Please describe your current and past history with the following substances:
Tobacco/smoking:
Alcohol:
Other drugs:
When was your last medical exam?
Family History
Please give a brief description of your family (parents, spouse, children, siblings, etc.)
Has anyone in your family been diagnosed with mental health issues or experienced addiction and/or substance abuse? If so, please describe.
Current Situation and Support System
Please describe any recent life changes or stressors that may have occurred (or are occurring) in your life.
Who are the people in your life you consider to be most supportive or helpful?
Strengths
What do you consider to be your greatest strengths (relationships, personality traits, skills, characteristics, etc.)?
Other
Is there anything else that you’d like me to know about you?
Submit
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