Counseling Intake Form

Counseling Intake Form
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Church Affiliation or Organization you are associated ?
Date of Birth

MonthDayYear
Date
Marital Status
Email
example@example.com
Employment
What is your occupation and work shift? 1st shift-Mornings, 2nd shift-Evenings, 3rd shift- Overnights
Primary Care Provider
Referral Name or referring Agency?

First NameLast Name
Home Phone
Cell Phone
Preferred Method of Contact

E-mailHome PhoneCell Phone
Emergency Contact Information
Name

First NameLast Name
Phone Number
Relationship
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Is there a family history of mental Illness?
Have you ever been hospitalized in an in-patient psychiatric unit?
Give details Concerning when? Where and what year?
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
Are you currently taking prescription medication?

YesNo
Are you currently taking prescription medication for a diagnosed mental Illness?

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone
Have you had any surgeries in the past 5 years?

YesNo
Please specify:
Mental Health History
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Therapist Name

First NameLast Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature

Clear

Counseling Intake Form

Emergency Contact Information

Medical History

Mental Health History