Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -.

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1 New Client Intake Date: Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -. Employer Emergency Contact Name Relationship Phone number TREATMENT HISTORY Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere? No Yes: if yes where? Have you had previous psychotherapy? No Yes: if yes with whom? Are you currently taking prescribed psychiatric medication (antidepressants or others)? No Yes: if yes please list name, dosage, and frequency. HEALTH AND SOCIAL INFORMATION Do you currently have a primary physician? No Yes: if yes who? 1

2 Have you ever experienced any of the following? Extreme depressed mood Dramatic mood swings Rapid speech Extreme anxiety Panic attacks Phobias Sleep disturbances Hallucinations Unexplained losses of time Unexplained memory lapses Alcohol/substance abuse Frequent body complaints Eating disorder Body image problems Repetitive thoughts (e.g. obsessions) Repetitive behaviors (e.g. frequent checking, hand washing) Homicidal thoughts Suicidal attempts If yes, when? OCCUPATIONAL/EDUCATIONAL INFORMATION Are you currently employed or in school? No Yes If yes, who is your currently employer/school? If yes, are you happy with your current position? Please list any work or school-related stressors, if any 2

3 Briefly describe what has brought you to counseling: RELIGIOUS/SPIRITUAL INFORMATION Do you consider yourself to be religious? No Yes If yes, what is your faith? If no, do you consider yourself to be spiritual? No Yes FAMILY MENTAL HEALTH HISTORY Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following? (circle any that apply and list family member, e.g. sibling parent, uncle, etc.) Difficulty Family member Depression Bipolar disorder Anxiety disorder Panic attacks Schizophrenia Alcohol/substance abuse Eating disorders Learning disabilities Trauma history Suicide attempts Chronic illness 3

4 What are your goals for therapy? Client signature: Date: If client is under the age of 18: Guardian signature: Date: Counselor signature: Date: 4

5 Medications Please include all medications taken daily Name of Medication Dose Prescriber Frequency Prescribed Taken as Prescribed? Expected result 5

6 HIPPA COMPLIANCE Consent for the use and disclosure of protected health information, as required by HIPPA, Kairos Counseling Services may use your personal health information for the purpose of treatment, payment, or health care operation. The specified uses and disclosures that we intend to make are described in our notice of information practices. You may request restrictions on these uses and disclosures described in the NOI by describing the requested restrictions in the Restriction request action form. You may revoke this consent at any given time by signing and dating the revocation section on your copy of the form and returning it to the office. As a recipient or Parent/Guardian of a recipient, I hereby consent to the use and disclosure of my/my child s/my ward s personal health information for the purpose of treatment, payment, and healthcare operations. My signature below indicates that I have been given the opportunity to read the Notice of Information Practices and to have any questions answered before signing. I understand that I may request restrictions on the uses and disclosures of my health information at any time by completing and signing the restriction request. I further understand that I may revoke this consent at any time by signing the revocation form and returning it to Kairos Counseling Services. I further understand that any such revocation does not apply to me in the event that persons already authorized to use or disclose my health information have already acted in reliance to this consent. Recipient/Guardian Signature: Date: Kairos Employee Witness: Date: 6

7 Optional Cultural Orientation Form I do not wish to participate Signature: Last Name First Name MI DOB: Age: Sex: Preferred Language: Relationship Status: Race: Ethnicity: Single parent? No Yes Employed? No Yes Sexual orientation: Highest level of education: 7

8 Permission for Evaluation & Treatment As a recipient, Parent, or legal guardian of a recipient, I hereby give informed consent to Kairos Counseling services to provide an evaluation, and behavioral healthcare services to myself, my child, or my ward. This consent will expire 1 year from the date signed. Signature: Print: Relationship: Kairos Employee Witness: Print: Date: 8

9 THERAPIST NOTES: CHIEF COMPLAINT HISTORY: GOALS: 9