"Confidential Client Intake Form - Hope Counseling Center"

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CONFIDENTIAL CLIENT INTAKE FORM
Name:
Today’s Date:
Sex:
Male
Female
Date of Birth:
Age:
Address:
City:
State:
Zip:
Phones: (W)
(H)
(C)
Any number you do not want to be contacted at:
Email:
Check here if you want Christian counseling
Do you regularly attend a church, synagogue, or other religious institution?
Yes
No
If yes, which one?
RELATIONAL INFORMATION
Current marital status:
Single
Engaged
Married
Separated
Divorced
Widowed
If engaged, married, separated, divorced, or widowed, for how long?
Number of previous marriages for you:
For your spouse:
If married, spouse’s name:
Age:
Is your spouse supportive of you seeking counseling?
Yes
No
Unsure
Spouse doesn’t know
Please provide a brief description of your spouse (e.g., angry and controlling; outgoing and supportive):
What is your current occupation?
What is your level of satisfaction with your occupation?
Please list your children (including step, adopted, foster) below:
Name
Sex
Age or yr. of death
Relationship to you
Living with whom?
Who else lives with you?
CONFIDENTIAL CLIENT INTAKE FORM
Name:
Today’s Date:
Sex:
Male
Female
Date of Birth:
Age:
Address:
City:
State:
Zip:
Phones: (W)
(H)
(C)
Any number you do not want to be contacted at:
Email:
Check here if you want Christian counseling
Do you regularly attend a church, synagogue, or other religious institution?
Yes
No
If yes, which one?
RELATIONAL INFORMATION
Current marital status:
Single
Engaged
Married
Separated
Divorced
Widowed
If engaged, married, separated, divorced, or widowed, for how long?
Number of previous marriages for you:
For your spouse:
If married, spouse’s name:
Age:
Is your spouse supportive of you seeking counseling?
Yes
No
Unsure
Spouse doesn’t know
Please provide a brief description of your spouse (e.g., angry and controlling; outgoing and supportive):
What is your current occupation?
What is your level of satisfaction with your occupation?
Please list your children (including step, adopted, foster) below:
Name
Sex
Age or yr. of death
Relationship to you
Living with whom?
Who else lives with you?
Please list your father, mother, sisters, brothers, stepfamily relations, or other family members who had a significant effect on
your life (either positive or negative). (Use the back of this sheet if necessary.)
Name
Sex
Age or yr. of death
Relationship to you
Describe him/her (e.g. angry, out-
going, supportive, controlling)
COUNSELING HISTORY
If you have had any previous counseling, psychiatric treatment, substance abuse treatment, or residential/in-patient care, please
list the names of the therapists or programs. (Use the back of this sheet if necessary.)
Therapist’s Name or Program
Major Issue
Dates
Has anyone in your family ever been treated or hospitalized for substance abuse, mental health issues, or psychiatric conditions?
Yes
No
If yes, please describe:
Have any of your family members or friends ever attempted or committed suicide?
Yes
No
If yes, who and when:
MEDICAL HISTORY
Please list any conditions, illnesses, treatments, or surgeries that might be relevant to your reason for seeking counseling:
Are you currently receiving any medical treatment?
Yes
No If yes, please describe:
Please list all current medications you are taking and the reasons for taking them. (List even if you seldom use, or take
only as needed.)
Name of medications
Dose
Reason for taking
Are you taking these medications according to the doctor’s recommendations?
Yes
No
If no, please explain:
Date and outcome of last physical exam:
PRESENT ISSUES AND GOALS
Please describe why you are coming to counseling. (i.e. what are your issues, problems, symptoms, how long, etc. Use the back
if necessary.):
Check any of the following symptoms or problems that you currently are or recently have experienced:
List 1
List 2
List 3
Stress
Marital Problems
Compulsive Behaviors
Anxiety
Other Relational Problems
Seeing Things Others Don’t
Panic
Physical Abuse
Hearing Voices
Depression
Emotional Abuse
Racing Thoughts
Apathy
Verbal Abuse
Eating Problems
Fatigue/Lack of Energy
Sexual Abuse
Drug Use
Loss of Appetite/Overeating
Sexual Problems
Alcohol Use
Trouble Sleeping
Gender Identity Issues
Pregnancy
Poor Concentration
Anger
Abortion
Feeling Worthless
Aggressive Behavior
Legal Matters
Recent Death
Bad Dreams
Work Stress
Grief
Unwanted Memories
Career Choices
Chronic Pain
Loss of Control
Indecisiveness
Loneliness
Impulsive Behavior
Parenting Problems
Fears
Controlling
Financial Problems
Shyness
Controlled by Others
Spiritual Problems
Low Self-Esteem
Obsessive Thoughts
Other
Please use an “X” on the scale below to indicate how distressing your problem(s) are to you.
Very Minimally
Moderately
Very Extremely
Distressing
Distressing
Distressing
Are you currently experiencing any suicidal thoughts?
Yes
No
Have you experienced suicidal thoughts in the past?
Yes
No
Have you attempted suicide in the past?
Yes
No
Are you currently experiencing any violent or homicidal thoughts?
Yes
No
What do you hope to gain from this counseling experience?
Client’s Signature
Date
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