Standard Intake Form
To enhance the efficiency of our service delivery, we kindly request that you complete the enclosed standard intake form in its entirety. Your thorough completion of this form is essential to ensuring a seamless process for your entry into our services.It is important to note that this intake form is fully compliant with the Health Insurance Portability and Accountability Act (HIPAA), ensuring the confidentiality and security of your personal information.Your cooperation in providing accurate and comprehensive information will contribute significantly to our ability to tailor our services to meet your specific needs. If you have any questions or require assistance while completing the form, please do not hesitate to reach out to our dedicated team.Thank you for your commitment to this process, and we look forward to serving you effectively.
Clients' Legal Name: (This is the person receiving services)
*
First Name
Last Name
Social Security Number
*
Address
*
Street Address
City, State
Zip
Phone Number
Email Address
What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can:
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What are your goals for counseling?
Have you seen a mental health professional before?
*
Yes
No
Specify all medications and supplements you are presently taking and for what reason. If none please enter N/A
*
If taking prescription medication, who is your prescribing medical doctor (MD)? Please include type of MD, name and phone number.
Who is your primary care physician (PCP)? Please include type of MD, name and phone number. If you do not have a PCP please enter N/A
Do you drink alcohol?
Yes
No
Do you use recreational drugs?
Yes
No
Do you have suicidal thoughts?
Yes
No
Have you ever attempted suicide?
Yes
No
Do you have thoughts or urges to harm others?
Yes
No
Have you ever been hospitalized for a psychiatric issue?
Yes
No
Is there a history of mental illness in your family?
Yes
No
If you are in a relationship, please describe the nature of the relationship and months or years together.
Describe your current living situation. Do you live alone, with others. With family, etc...
What is your level of education? Highest grade/degree and type of degree.
What is your current occupation? What do you do? How long have you been doing it?
Please check any of the following you have experienced in the past six months:
Increased appetite
Decreased appetite
Trouble concentrating
Difficulty sleeping
Excessive sleep
Low motivation
Isolation from others
Fatigue/low energy
Low self-esteem
Depressed mood
Tearful or crying spells
Anxiety
Fear
Hoplessness
Panic
Other
Please check all that apply:
Headache
High blood pressure
Gastritis or esophagitis
Hormone-related problems
Head injury
Angina or chest pain
Irritable bowel
Chronic pain
Loss of consciousness
Heart attack
Bone or joint problems
Seizures
Kidney-related issues
Chronic fatigue
Dizziness
Faintness
Heart valve problems
Urinary tract problems
Fibromyalgia
Numbness & tingling
Shortness of breath
Diabetes
Hepatitis
Asthma
Arthritis
Thyroid issues
HIV/AIDS
Cancer
Other
What else would you like us to know?
Client's Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: