MMH Counseling Client Intake Form
Peggy Hinders, LPC
Please provide the following information prior to your first session. Try and be as complete as possible. Please note: Information you provide here is protected as confidential through HIPAA Regulations.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Age
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Employer
Position/Title
How did you hear about my practice?
Relationship Status
Single
Married
Separated / Divorced
Widowed
In a Relationship
If married, or in a relationship, how long?
Previous Marriage
Yes
No
Spouse Name (if Applicable)
Spouse Age
Spouse Employer
Spouse Position/Title
Has your Spouse had a previous marriage?
Yes
No
Do You have Children or Step-Children?
Yes
No
Please enter Names and Ages
Have you previously received any type of counseling or mental health services?
Yes
No
If yes... please provide details. Did it help?
List medications you are currently taking and/or any medical diagnosis
List any side effects of these medications
Do you exercise? If yes, please describe
Do you take prescription birth control and/or HRT?
Yes
No
N/A
Have you had a hysterectomy?
Yes
No
N/A
Do you take Testosterone
Yes
No
Do you drink alcohol?
Yes
No
If yes... how much/often do you drink?
Has alcohol usage been a problem in your life/relationship(s)?
Yes
No
If yes, please provide more details
Do you smoke?
Cigarettes
Marijuana
Vapor
N/A
What type of significant life changes or stressful events have you experienced recently?
What do you see as your strengths, skills or limitations?
Do you consider yourself spiritual or religious?
Yes
No
Please describe your faith or belief.
What would you like to accomplish during your time in therapy?
Is there any other information that I need to know in order to help you achieve your counseling goals?
Thank you for taking the time to complete this questionnaire. I look forward to meeting with you. Peggy
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