Intake & Consent Form

C:\fakepath\Intake & Consent Forms.pdf

Please complete the form below or click the Intake & Consent Forms.pdf above and bring to your appointment.


Contact Information

Full Name:


Types of Counseling:


Individual Couples Pre-Marital Family Group Evaluation


Address: City/State/Zip:


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


Race/Ethnicity:


Please list any children/age:


Legal Issues:


Name of Parent/Guardian (if client is under 18yrs):


How did you hear about us? Internet Referral Other:



Insurance

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.

Please Select One

List Family Member

Alcohol/ Substance Abuse

Yes No

Anxiety

Yes No

Depression

Yes No

Eating Disorder

Yes No

Obesity

Yes No

Obsessive Compulsive Behavior

Yes No

Schizophrenia

Yes No

Suicide Attempts

Yes No


Additional Information


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?