Counseling Intake Assessment

Please answer all questions to the best of your ability.

Please talk with your provider if you have questions about this form.

I'm filling this form out for...*

If you are filling this out for a child/youth client, please use their answers for the questions. Add any additional notes of your own at the bottom of the form.

Person Completing the Form

First NameLast Name

Relationship to Client

Client Full Name*

First NameLast Name

Client Preferred Name

If different from legal name

Client Preferred Email

example@example.com

Client Date of Birth*

Gender Identity

For example: Female, Male, Nonbinary, Transgender, etc.

Birth Sex

Preferred Pronouns

For example: She, He, They, Etc.

How did you hear about our practice?

We'd love to thank the person who referred you to us if you want to provide their name & email.

Name & Email would be awesome!

Medical & Mental Health History

Medications & Supplements currently prescribed & taking

Please include dosage and frequency

Do you have any medical conditions or chronic illnesses?

NoYesNot Sure

Please provide a brief description of your medical conditions.

Diagnosis, time frame, treatment, etc.

Treatment History

Have you had Individual Mental Health Counseling in the past?

YesNo

Share a brief description of past counseling experience

Dates, locations, provider traits you liked or disliked, etc.

Have you had Intensive Treatment in the past (inpatient, Partial Hospitalization- PHP, IOP, etc.)?

YesNo

Share a brief description of past intensive treatment experience

Dates, treatment programs, aspects your like or disliked, etc.

Has anyone in your family been diagnosed or been treated for mental health concerns?

YesNoNot Sure

Share a brief description of mental health challenges in your family.

Family member, diagnosis or treatment, etc.

Presenting Concerns

Have you had experiences that you would consider Traumatic?

YesNoNot Sure

Please share when you experienced trauma. Check all that are applicable.

Please share which of these apply to your trauma. Check all that apply.

PhysicalEmotionalSexualOther

Do you struggle with food or body image?

YesNoNot Sure

Please share a little more about how often you struggle with these food & body related behaviors:

	Never	Rarely	Sometimes	Weekly	Daily
Dieting & Restricted eating
Body Checking & Weight monitoring
Purging
Pills or supplements for weight control
Extreme or intense exercise
Avoiding things due to food or body struggles

Substance Use

Please share the frequency of any Substance Use:

	Never	Rarely	Sometimes	Weekly	Daily
Caffeine
Alcohol
Nicotine
Marijuana
Recreational Prescription Drug Use
"Street" Drug Use

Any additional Substance Use Information?

Quantities, details, past use, quit date(s), etc.?

Mood Questionnaire

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

	Not at all	Several Days	More than Half the Days	Nearly Every Day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling asleep, staying asleep or sleeping too much
Feeling bad about yourself or that you are a failure and have disappointed someone.
Feeling tired or having little energy
Trouble concentrating on things like reading or watching shows or movies
Moving slow or speaking slow
Thoughts that you'd be better off dead or of harming yourself

	Not Difficult at all	Somewhat Difficult	Very Difficult	Extremely Difficult
If you checked any of the above mood questions, 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?

Anxiety & Worry Questionnaire

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

	Not at all	Several Days	More than Half the Days	Nearly Every Day
Feeling Nervous, Anxious or "on edge"
Intrusive Worry
Worrying about many different things
Being so restless that is is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Trouble Relaxing

Coordination of Care

Please check any other Healthcare Providers you are currently seeing

Please consider filling out a Release of Information for each provider so we can coordinate care as needed. You can click on this link and complete the Release now or save this link address to complete it later.

https://form.jotform.com/discoverycounseling/release-of-information

If there is anyone else who is part of your care team or needs to be informed about your counseling, please list them here & complete a Release of Information for them.

Goals

List 3 Goals for Counseling:

Goals can be anything you want to change, enhance or accomplish.

List 3 Personal Strengths:

Strengths can be internal or external to you.

List 3 Limitations that would keep you from reaching your counseling goals:

Limitations can be internal or external.

If there is anything you haven't shared yet and you'd like to include it, please share it here:

Counseling Intake Assessment Form