Please complete the form below or click the Intake & Consent Forms.pdf above and bring to your appointment.
Types of Counseling:
Individual Couples Pre-Marital Family Group Evaluation
Home Phone: May we Leave a voice message? Yes No
Cell/Other: May we Leave a voice message? Yes No
Email Address: May we email you? Yes No
Emergency Contact Name: Relationship: Phone:
Date of Birth (Month, date, Year): Social Security Number: Age:
School Name: Highest Level of Education:
Gender Assigned at Birth: Male Female
Current Gender Identity: Male Female Transgender Do not identify as male, female or transgender
Please list any children/age:
Name of Parent/Guardian (if client is under 18yrs):
How did you hear about us? Internet Referral Other:
Insurance: Policy Holder:
Policy Number: Group:
EAP Name: Authorization:
Effective Date of Insurance: Phone Number:
General Health Information
Are you currently taking any prescription medication? Yes No If Yes, please list:
How would you rate your current physical health? Poor Unsatisfactory Satisfactory Good Very Good
Please list any specific health problems you are currently experiencing:
How would you rate your current sleeping habits? Poor Unsatisfactory Satisfactory Good Very Good
Please list any specific sleep problems you are currently experiencing:
How many times a week do you generally exercise? 0-1 2-3 4-5 6-7 7 or more
Why type of exercise do you participate in?
Please list any difficulties you experience with your appetite or eating patterns:
Mental Health Information
Have you previously received any type of mental health services (such as psychotherapy, psychiatric services, etc.)? Yes No
If yes, please list previous therapist/ practitioner:
Have you ever been prescribed psychiatric medication? Yes No If Yes, please list and provide dates:
Are you currently experiencing overwhelming sadness, grief or depression? Yes No If yes, for approximately how long?
Are you currently experiencing anxiety panic attacks or have any phobias? Yes No
If yes, approximately when did you begin experiencing this?
Are you experiencing any chronic pain? Yes No If yes, please describe. ________________________________________________
Do you drink alcohol? Yes No If Yes, how often: Once a week Twice a week Three or more times a week
How often do you engage in recreational drug use? Daily Weekly Monthly Infrequently Never
Are you currently in a romantic relationship: Yes No If yes, for how long?
On a scale of 1 - 10, how would you rate your relationship?
What significant life challenges or stressful events have you experienced recently?
Family Mental Health History
In the section blow identify if there is a family history for any of the following. If yes, please indicate the family member’s relationship to you in the space provided.
Are you currently employed? Yes No
If yes, what is your current employment situation?
Do you enjoy your work? Yes No
Is there anything stressful about your current employment situation?
Do you consider yourself to be spiritual or religious? Yes No
If yes, please describe your faith or belief:
What do you consider to be your strength?
What do you consider to be your weakness?
What would you like to accomplish out of your time in therapy?