"Counseling Intake Form"

ADVERTISEMENT
ADVERTISEMENT

Download "Counseling Intake Form"

Download PDF

Fill PDF online

Rate (4.3 / 5) 9 votes
COUNSELING INTAKE FORM
PLEASE NOTE: ALL INFORMATION WILL BE KEPT CONFIDENTIAL
Date:________________________
Birth Date:________________________
Name:_________________________________________________________________________________________________
Address:__________________________________________City/St_________________________ Zip:______________
Your Phone #’s: (Home)__________________________________, (Work)_________________________________
( C e l l ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P r e f e r r e d m e t h o d o f c o n t a c t :
______________________________
Email Address:_______________________________________________________________________________________
Your Employment/Job Title/School:_______________________________________________________________
Person responsible for your bill, if different than above:
_________________________________________________________________________________________________________
Referral Source (e.g., how you found out about services)________________________________________
Is it ok to call your home & leave message: Yes_____ No_____; At your work: Yes_____ No_____
Person to contact in case of an emergency (name/phone):______________________________________
In a few words, describe your reason for seeking counseling:___________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Have you ever had counseling before? ______Yes ______No
If yes, describe and list counselor, estimated number of sessions, any psychiatric
hospitalizations:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Describe any major changes that have occurred to you or your family in the last few years
(moves, changes in number of family members, marital status, situation or income):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
COUNSELING INTAKE FORM
PLEASE NOTE: ALL INFORMATION WILL BE KEPT CONFIDENTIAL
Date:________________________
Birth Date:________________________
Name:_________________________________________________________________________________________________
Address:__________________________________________City/St_________________________ Zip:______________
Your Phone #’s: (Home)__________________________________, (Work)_________________________________
( C e l l ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P r e f e r r e d m e t h o d o f c o n t a c t :
______________________________
Email Address:_______________________________________________________________________________________
Your Employment/Job Title/School:_______________________________________________________________
Person responsible for your bill, if different than above:
_________________________________________________________________________________________________________
Referral Source (e.g., how you found out about services)________________________________________
Is it ok to call your home & leave message: Yes_____ No_____; At your work: Yes_____ No_____
Person to contact in case of an emergency (name/phone):______________________________________
In a few words, describe your reason for seeking counseling:___________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Have you ever had counseling before? ______Yes ______No
If yes, describe and list counselor, estimated number of sessions, any psychiatric
hospitalizations:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Describe any major changes that have occurred to you or your family in the last few years
(moves, changes in number of family members, marital status, situation or income):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Educational history: Last year of school completed: _____________________ (or GED)
College: 1 2 3 4 Degree:___________________________________ Other: ______________________________
Single______ Married_______ Separated______ Divorced_____ Remarried______ Widowed_____
Do you have children? _________ Yes _________ No
If yes, list names, ages, and whether they live in your home
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Has anyone in your family ever had counseling before? If so, for what?________________________
_________________________________________________________________________________________________________
Any history of drug/alcohol abuse for self, father, mother, siblings? _____ Yes _____ No
If yes, please describe _______________________________________________________________________________
Do you use alcohol or nonprescription drugs? _____Yes _____No
If yes, describe frequency and type_________________________________________________________________
List any major health problems for which you have received treatment for in the last 24
months:
_________________________________________________________________________________________________________
Primary Care Physician: ____________________________________________________________________________
Phone:____________________________________
Are you taking any prescription drugs at this time? _____Yes _____No
If yes, what type, for what purpose, and who prescribed?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Page of 2