"Adult Intake Form"

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ADULT INTAKE FORM
Demographic Information:
Name: _______________________________________________ D.O.B.: _____________________________
Address: _____________________________________________ Age: ________________________________
_____________________________________________ Relationship Status:________________
Significant Others Name: ____________________________
Phone: _______________________________________________ Can I leave a message? □ Yes □ No
Secondary Phone: ___________________________________ Can I leave a message? □ Yes □ No
Email: ________________________________________________ Can I email here?
□ Yes □ No
How were you referred?____________________________________________________________________
Family History:
Describe your family structure growing up: _______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Describe relationships among your family members growing up: ________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How would you describe your upbringing? _______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How would you describe your teenage years? ____________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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ADULT INTAKE FORM
Demographic Information:
Name: _______________________________________________ D.O.B.: _____________________________
Address: _____________________________________________ Age: ________________________________
_____________________________________________ Relationship Status:________________
Significant Others Name: ____________________________
Phone: _______________________________________________ Can I leave a message? □ Yes □ No
Secondary Phone: ___________________________________ Can I leave a message? □ Yes □ No
Email: ________________________________________________ Can I email here?
□ Yes □ No
How were you referred?____________________________________________________________________
Family History:
Describe your family structure growing up: _______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Describe relationships among your family members growing up: ________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How would you describe your upbringing? _______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How would you describe your teenage years? ____________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has anyone in the child’s family experienced the following:
□Mental health illness Type: ____________________________ Relationship to you: ____________
□Abuse or trauma
Type: _____________________________ Relationship to you: ____________
□Drug/alcohol abuse Type: _____________________________ Relationship to you: ____________
□Suicidal behaviors
Type: ______________________________ Relationship to you: ____________
Length of time in jail: _________________ Relationship to you: ____________
□Incarceration
Employment & Education Information:
Current Employment Status: _____________________ Employer: ______________________________
Position Title: _______________________________________________________________________________
Education Experience: ______________________________________________________________________
Current Concerns:
What concern brings you into counseling? ________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
When did these concerns begin? __________________________________________________________
_____________________________________________________________________________________________
Please describe significant events occurring at that time, or since then, which may relate
to the development of this concern: _______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you having difficulties or stress at your current job? __________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Are you having difficulties with your current significant other? ___________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you having difficulties in any of your relationships with other people? _______________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please check any behaviors that apply to you:
□Drug usage
□Sleeping issues
□Aggression
□Angry outbursts
□Eating Disorders
□Self-harm/injury
□Suicidal attempts
□Avoidance
□Grieving
□Can’t keep a job
□Impulsive reactions
□Take risks
□Inappropriate boundaries
□Compulsions
□Vomiting
□Concentration difficulties
□Loss of Control
□Withdrawal
□Lack of Motivation
□Work too much
□Crying
□Drink too much
□Other: ____________
□Procrastination
Please check any feelings that stand out to you below:
□Alone
□Fearful
□Regretful
□Anger
□Guilty
□Relaxed
□Annoyed
□Happy
□Restless
□Anxious
□Helpless
□Sad
□Bored
□Hopeful
□Shameful
□Conflicted
□Hopeless
□Tense
□Depressed
□Lonely
□Unhappy
□Energetic
□Optimistic
□Unloved
□Envious
□Panicky
□Upset
□Other: ____________
□Excited
□Powerless
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Please check any physical symptoms that apply to you:
□Hearing things
□Stomach trouble
□Blackouts
□Don’t like being touched
□Nightmares
□Tension
□Fainting spells
□Rapid heart beat
□Tics
□Seeing things
□Fatigue
□Tremors
□Sexual disturbances
□Unable to relax
□Headaches
□Other: ____________________
Other concerns or difficulties you have: ___________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Goals for counseling: ______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Have you attended counseling before? □ Yes □ No Dates: _______________________________
Reasons for previous counseling: __________________________________________________________
_____________________________________________________________________________________________
Do you have a previous mental health diagnosis? _________________________________________
_____________________________________________________________________________________________
Have you had any significant losses? (death, job loss, pet lot, miscarriage etc.) ___________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Have you ever been abused or experienced any trauma? _________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Have you ever been admitted to a psychiatric hospital? □ Yes □ No Date: ________________
Length of stay: ______________ Reasons: ____________________________________________________
_____________________________________________________________________________________________
Medical History:
Have you ever been hospitalized for an illness? ___________________________________________
_____________________________________________________________________________________________
Medications:
Name: ________________________ Purpose: _____________ Dosage: _______ Frequency: _________
Name: ________________________ Purpose: _____________ Dosage: _______ Frequency: _________
Name: ________________________ Purpose: _____________ Dosage: _______ Frequency: _________
Name: ________________________ Purpose: _____________ Dosage: _______ Frequency: _________
Is there any other information about you that you feel is helpful for me to know? _________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________
__________________________
Person completing this form
Date
_______________________________________________________________
Signature
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