Client Name: Age: DOB: Date: What brings you to therapy?: How long has the problem been present?

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1 Hope in Healing Counseling and Wellness, LLC Stacy Nunne, MA, LMFT, SEP, RN 600 West 78th Street, Suites 10A-C Mailing Address: PO Box 892 Chanhassen, MN Chanhassen, MN Phone: Fax: Adult Psychotherapy Intake This form is intended to help your counselor become better acquainted with you and, in turn, serve you better. You may omit any item, but try to be as thorough as possible. Please use the back if you need more space. Thank you. Client Name: Age: DOB: Date: What brings you to therapy?: How long has the problem been present? What solutions to the problem have you tried, and what were the results? How much does this problem affect your life personally? How much does this problem affect your family life? How much does this problem affect your social life? How much does this problem affect your work? How much does this problem affect your health? Have there been any significant changes in your life recently? Yes No If yes, please describe: Have you ever thought about, planned, or attempted suicide? Yes No If yes, please describe: Have you ever thought about, planned, or attempted to harm or kill someone else? Yes No If yes, please describe: Are you currently under the care of a psychiatrist? Yes No Psychiatrist: Phone Number: Address: City: State: Zip: Diagnosis: Date Do you agree? Have you ever been hospitalized for psychiatric reasons? Yes No Hospital Reason for Hospitalization Dates Have you ever been under the care of a therapist? Yes No If so, with who and when? Therapist Approximate Dates Helpful? Are you currently taking any Psychiatric Medications? Yes No Medication/dosage Prescribed by Prescribed for Dates Helpful? Hope in Healing Counseling and Wellness, LLC, Adult Psychotherapy Intake (revised ) Page 1 of 6

2 Mental Health Concerns (Please put C-Current and/or P-Past for all that apply to you): ADHD/Learning Concerns Episodes of Manic Behavior Obsessive Thoughts Adjustment Problems Family Concerns/Problems Panic Attacks Alcohol Dependence Feeling Detached from your Body Paranoia Alcohol or Drug Concerns Feeling Doomed or Helpless Phobias/Fears Anger Management Concerns Financial Concerns Physical Abuse or Assault Anxiety, Fear, Nervousness Graduation Concerns Procrastination Career/Job Concerns Grief and/or Loss Recurring Thoughts Change in Appetite Hallucinations School Concerns Change in Sleep Habits Harassment Self-Mutilation/Injury Compulsive Behavior Identity/Sense of Self Concerns Stress Concentration Difficulties Impulse Control Concerns Thoughts are Disorganized Cultural Concerns Internet/Video use Concerns Unable to Relax Depression Irritability Withdrawal and Loss of Interest Decreased Interest in Activities Judgment Errors Other Eating Concerns Memory Impairment Other Eating Disorder Mood Shifts Other Please explain any of above: General Health Information Primary Care Physician: Phone Number: Address: City: State: Zip: Most recent medical examination(s): Who else do you see as a part of your regular health care routine? (Specialists/Doctors, Chiropractor, Acupuncturist, Physical Therapist etc.): Are you currently taking any medications for medical conditions? Yes No Medication/dosage Prescribed by Prescribed for Dates Helpful? Do you take any vitamin supplements? Yes No What? Please List any Health Problems or Concerns (Please put C-Current and/or P-Past for all that apply to you): Abdominal pain Diabetes Irritable bowel Sinus infections Acne Dizziness Joint problems Shingles Allergies Ear infections Kidney disease Skin problems Anemia Eating problems Memory problems Sleeping problems Asthma Fatigue Migraines Speech problems Blackouts Fevers Muscle spasms/twitch Sexuality Issues Bleeding tendency Fibromyalgia Neck/back pain Stomach problems Cancer Frequent injuries Numbness/tingling Tetanus Chest pains Head injury Overweight/underweight Tics/tremors Colds/coughs Headaches Rashes Thyroid problems Congenital problems Heart trouble Respiratory illness Weight gain/loss Chronic pain Hepatitis Seasonal flu Other Dental problems High blood pressure Seizures Other Please list any other health issues that you would like me to be aware of: Hope in Healing Counseling and Wellness, LLC, Adult Psychotherapy Intake (revised ) Page 2 of 6

3 How would you rate your current physical health? (Please circle) How would you rate your current energy level? (Please circle): How would you rate your current sleep patterns? (Please circle): What sleep issues, if any, do you have? Choose all that apply Difficulty falling asleep Difficulty getting up in the morning Difficulty staying asleep Nightmares How many hours of sleep do you get per night? Hours of uninterrupted sleep? How would you rate your current eating habits? (Please circle): How is your appetite?: Weight gain or loss?: How much?: Are you concerned about your eating? Yes No Are others concerned about your eating? Yes No Whom? How much do you exercise a week?: Are you concerned about your exercising? Yes No Are others concerned? Yes No Whom? Have you had any hospitalizations/surgeries? Yes No List/Dates: Alcohol or Substance Use (CAGE/CAGE-AID) Please describe your use of the following: Do you drink alcohol? Yes No How often? Do you use Drugs/Chemicals? Yes No How often? In the last three months, have you felt you should cut down or stop drinking or using drugs? Yes No In the last three months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs? Yes No In the last three months, have you felt guilty or bad about how much you drink or use drugs? Yes No In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs? Yes No Have you ever been in treatment for alcohol or chemical dependency? Yes No Treatment Center/Hospital (Include inpatient, outpatient, detox) Date Current Relationship (more than one may apply): Relationship Status: Single Dating Engaged Married Partnered Domestic Partnership Civil Union Separated Permanently Separated Divorced Widowed Other/Explain: Total number of marriages: Sexual Orientation: Comments: Name of Spouse/Partner: Age: Are you living together? Yes No How long have you been together? Married how long? How would you describe your relationship? What are your relationship strengths? If you have any problems in your current relationship, please describe: Please describe any past relationships of significance: Hope in Healing Counseling and Wellness, LLC, Adult Psychotherapy Intake (revised ) Page 3 of 6

4 Sexual History Please List any sexual health problems or concerns (Please put C-Current and/or P-Past for all that apply to you): Abortion Pornography Concerns Sexuality Concerns Infertility Problems/Concerns Sexual Assault Sexually Transmitted Infection(s) Loss of Interest in Sex Sexual Problems Unwanted Pregnancy Pain with Intercourse Sexual Trauma Other: Other problems that keep you from enjoying sex?: How satisfying is your sex life? (1 worst 5 best) Family Information Living Resides with you? Children Age Yes No Yes No List any concerns about your children?: Family History --Please list all significant parental relationships Living Resides with you? Name Age Yes No Yes No Mother: Father: Step-Mother: Step-Father: Other: Other: If your parent is deceased, how old were you when he/she died? Are your parents: Currently legally married? Yes No How long? Separated? Yes No How long?: Parents divorced? Yes No Married how long? Mother remarried? # of times: Father remarried? # of times: Where do your parents live? Brothers and Sisters (Include Yourself): Living Name Describe Relationship Age Yes No Where did you grow up? and who did you live with? (Please list all places and people): How would you describe your family/family-relationships as you were growing up?: How would you describe your family/family-relationships now?: Hope in Healing Counseling and Wellness, LLC, Adult Psychotherapy Intake (revised ) Page 4 of 6

5 Development History Are there special, unusual, or traumatic circumstances that affected your development? Yes No If yes, please describe: Do you have a history of being abused? Yes No If yes, which type(s): Sexual Physical Verbal Emotional Neglect Inadequate Nutrition Inadequate Medical Attention Inadequate Dental Attention Is there anything else that happened to you in your childhood that you consider abuse?: Did anyone in your family of origin experience childhood abuse? Yes No If yes, Whom: Do you know anyone that committed suicide? Yes No If yes, Whom: Family Mental Health and Health History In the next section, identify if there is a family history of any of the following, if yes, please indicate the family member (father, grandmother, uncle, etc.). List Family Member (for example: aunt, brother, father) Alcohol Abuse Anxiety Bipolar Disorder Compulsive Behaviors Depression Domestic Violence Eating Disorders Learning Disabilities Obsessive Behavior Panic Disorders Schizophrenia Substance Abuse Suicide Attempts Trauma History Please list any family history of medical problems, indicate whom: Your Current Employment Status Full Time Part Time Temporary Laid off Disabled Retired Social Security Student Other (please describe): Job history-please begin with most recent. Occupation Employer Dates Do you have any concerns about your work?: Do you enjoy your work? Yes No On a scale of 1-10, how stressful is your work?: What is stressful about your current work? Culture/Ethnicity To which cultural or ethnic group, if any, do you consider you belong? Are you experiencing any problems due to cultural or ethnic issues? Yes No If yes, please describe: Are there any aspects of your culture or ethnicity that you would like your therapist to know? Hope in Healing Counseling and Wellness, LLC, Adult Psychotherapy Intake (revised ) Page 5 of 6

6 Education What is your highest level of education? Where did you go to school? School Degree Date Graduated Other training: Are you currently a student? Yes No If yes: full time or part time?(circle) School Attending? Spiritual/Religious Are you affiliated with a spiritual or religious group? Yes No If yes, please describe: How important to you are spiritual matters? (Please circle): Not at All A Little Somewhat Very Did you grow up within a spiritual or religious group? Yes No If yes, please describe: Would you like your spiritual/religious beliefs included in your counseling? Yes No If yes, please describe: Military Do you have military experience? Yes No Do you have combat experience? Yes No Location: Branch: Enlisted date: Date of discharge: Type of discharge: Rank at discharge: Do you have family members in the military? Yes No Who?: Legal Issues Are you involved in any active legal cases (traffic, criminal, civil)? Yes No If yes, please describe and include the charges and court and hearing/trial dates: Do you have involvement with any of the following people or services? Yes No If yes, please circle all that apply: County Social Worker Probation Officer Adult/Child Protection Guardian Ad Litem Please describe: Additional Personal Information Briefly describe your current support system/resources e.g. family, friends, organization social workers, community support organizations, church groups, and/or 12 step programs: What do you consider to be some of your personal strengths? What do you consider to be some of your areas of growth? Do you have hobbies or special interests? Yes No Describe: Is there anything else that you would like me to know about you? Is there anything else that you think would help you to have a positive therapy experience?: I acknowledge that the information on this form is accurate to the best of my knowledge, and that I will inform my counselor of any changes in my personal information. Client Signature: Date: Hope in Healing Counseling and Wellness, LLC, Adult Psychotherapy Intake (revised ) Page 6 of 6