"Intake Form - Journey Counseling Waco"

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JOURNEY COUNSELING WACO
209 Old Hewitt Rd., Suite C
Waco, TX 76712
File No._________________________________
Counselor __________________________________________
Today’s Date__________________________________
IDENTIFICATION
Name ____________________________________________ Age ______ Sex _____ Date of Birth ______________
Parent or Guardian (if under 18) ____________________________________________________________________
Address _________________________________________ City_______________ State _________ Zip__________
Home Phone ____________________ Work Phone ___________________ Cell Phone_________________________
Email __________________________________ SS # _____________________________
Preferred way to contact you _______________________________________________________________________
Restrictions _____________________________________________________________________________________
Person to call in an emergency, relationship to you ______________________________________________________
Phone ________________________________________
REFERRAL
How did you learn about us?_______________________________________________________________________
If an individual, may I have your permission to thank this person for the referral?
Yes _____ No _____
How did this person explain how I might help you? _____________________________________________________
C. MARITAL STATUS: Single [ ]
Engaged [ ]
Married [ ]
Common-law [ ]
Separated [ ]
Partner’s Name ______________________________________ Age _______ Date Married ______________
Divorced [ ] Number of times __________ When? _____________________________________________
Widowed [ ]
Date partner died ________________________________
EMPLOYMENT
Place of employment: ___________________________________ Gross Family Income ________________________
School (if student) ___________________________________________ Grade/ Year Level_____________________
Your education _____________________________ Partner’s Education ____________________________________
Partner’s place of employment __________________________________ Work Phone _________________________
Have you served in the military? ________ If so, what branch? ____________________________________________
Has your partner served in the military? _____ What branch? ______________________________________________
FAMILY OF ORIGIN
Parents Living/ Deceased (when?) Father _______________________Mother ________________________________
Parents Divorced? When? __________________________ Remarried? When? _______________________________
Your Place in Your Family of Origin: List your brothers and sisters including step and half-siblings, from left to right,
starting with the oldest on the left, to the youngest on the right. Include yourself and circle your name. Do the same
with your partner’s family.
Your Family _____________________________________________________________________________
Partner’s Family __________________________________________________________________________
CHILDREN/ STEPCHILDREN
Name
Sex
Age
Birthdate
Grade
School
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
JOURNEY COUNSELING WACO
209 Old Hewitt Rd., Suite C
Waco, TX 76712
File No._________________________________
Counselor __________________________________________
Today’s Date__________________________________
IDENTIFICATION
Name ____________________________________________ Age ______ Sex _____ Date of Birth ______________
Parent or Guardian (if under 18) ____________________________________________________________________
Address _________________________________________ City_______________ State _________ Zip__________
Home Phone ____________________ Work Phone ___________________ Cell Phone_________________________
Email __________________________________ SS # _____________________________
Preferred way to contact you _______________________________________________________________________
Restrictions _____________________________________________________________________________________
Person to call in an emergency, relationship to you ______________________________________________________
Phone ________________________________________
REFERRAL
How did you learn about us?_______________________________________________________________________
If an individual, may I have your permission to thank this person for the referral?
Yes _____ No _____
How did this person explain how I might help you? _____________________________________________________
C. MARITAL STATUS: Single [ ]
Engaged [ ]
Married [ ]
Common-law [ ]
Separated [ ]
Partner’s Name ______________________________________ Age _______ Date Married ______________
Divorced [ ] Number of times __________ When? _____________________________________________
Widowed [ ]
Date partner died ________________________________
EMPLOYMENT
Place of employment: ___________________________________ Gross Family Income ________________________
School (if student) ___________________________________________ Grade/ Year Level_____________________
Your education _____________________________ Partner’s Education ____________________________________
Partner’s place of employment __________________________________ Work Phone _________________________
Have you served in the military? ________ If so, what branch? ____________________________________________
Has your partner served in the military? _____ What branch? ______________________________________________
FAMILY OF ORIGIN
Parents Living/ Deceased (when?) Father _______________________Mother ________________________________
Parents Divorced? When? __________________________ Remarried? When? _______________________________
Your Place in Your Family of Origin: List your brothers and sisters including step and half-siblings, from left to right,
starting with the oldest on the left, to the youngest on the right. Include yourself and circle your name. Do the same
with your partner’s family.
Your Family _____________________________________________________________________________
Partner’s Family __________________________________________________________________________
CHILDREN/ STEPCHILDREN
Name
Sex
Age
Birthdate
Grade
School
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
RELIGIOUS AND RACIAL/ETHNIC IDENTIFICATION
Church membership ____________________________________ Minister ___________________________________
Religious preference _________________________________________________________________________
Involvement: None _______ Some/irregular _________ Active ________
How important are spiritual concerns in your life?
________________________________________________________________
Ethnicity/national origin ___________________________________ Race ___________________________________
Or other similar way you identify yourself and consider important __________________________________________
MEDICAL
Primary Care Physician ______________________________________ Phone _______________________________
Address ________________________________________ City ____________________ Zip ___________________
Relevant medical conditions (history, current condition) __________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Medications (dosage, dates of initial prescriptions, name of prescribing professional) ___________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Allergies _______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Do you have a learning or reading disability, such as dyslexia? ____________________________________________
Have you ever had a head injury? (falls, car accidents, etc.)? ______________________________________________
Do you use alcohol? _________ If so, how much per day__________ per week __________ per month ____________
Have you ever felt the need to cut down on your drinking? __________
Do you smoke? ________ If so, how much per day ________ per week __________ per month _________________
Have you ever used inhalants (“huffing”), such as glue, gasoline, or paint thinner? ___________ If yes, which and
when ? ________________________________________________________________________________________
Which drugs (not medications prescribed for you) have you used in the last 10 years? __________________________
_______________________________________________________________________________________________
Any family member with a drug or alcohol problem, past or present? _______________________________________
Previous Counseling/Psychotherapy History:
Date
Therapist/Agency
Reason for Termination
_______________________________________________________________________________________________
_______________________________________________________________________________________________
REASON FOR SEEKING COUNSELING TODAY: ________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
What supports do you have in your life right now?_____________________________________________
Who do you feel closest to today? __________________________________________________________
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
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