Introspective Counseling Services, LLC 6320 Evergreen Way Suite 213 Everett, WA (425)

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1 Intake Form Contact Information: Preferred _ Date of Birth: Preferred Pronoun: Gender: Ethnicity: Mailing Address: Residence Address: Phone Number in which its okay to leave a message: Emergency Contact: Phone Number: In the event of a medical emergency that occurs during our session, your emergency contact person will be contacted to facilitate medical follow up. Please review Counselor Disclosure Statement for specific details regarding the release of information in emergency circumstances. Referral Information: Doctor Friend College EAP Another Therapist Website Other: 1 of 16

2 Mental Health Information Please describe the main reason you are seeking counseling and what you hope to accomplish: How long has this been a concern? How would you describe your overall mental health? Excellent Good Fair Poor Please indicate major life stressors that have occurred in the most recent 12 months: Serious Injury or illness Serious Illness or Injury in Family Job Change New Member of Family Divorce/Separation Marriage/Partnered Death of a close friend or family member Other, please describe: Have you ever had any of these experiences? Cutting/Scratching Burning/Hitting Incarcerated/DUI/Legal Problems Anger/Losing Control Throwing up/laxatives Taking a lot of pills Reckless Driving Playing with weapons Thoughts about wanting to die Tried to kill yourself Physically injured someone Physically or Sexually Assaulted Stressed and went to the Emergency Room Have you ever received mental health counseling before? Purpose: From Whom? When? How long? Results: Are changing counselors? When was your most recent session 2 of 16

3 Have you ever been hospitalized due to mental health concerns? Situation: Where? Number of times? When? How long? Results: Have you ever been told that you have a mental health diagnosis? If yes, what diagnosis and which counselor or doctor provided the diagnosis: Were you prescribed medication for the mental health diagnosis? If yes, what was the name of the medication: Are you currently taking medication for your mental health? If yes, what is the name of the medication(s): Do you feel it is effective? If No, please explain: When was your most recent visit to your prescribing provider? 3 of 16

4 Social Network Information Intimate Partner Relationship Status: Married Committed Relationship Single Divorced Separated Widowed Number of Living Children (Biological/Adopted/Step, etc.): Number of Deceased Children (Biological/Adopted/Step, etc.): Persons living in the home with you (if none, write none) (more space is available on page 15): Other important persons in your life: Strengths, Interests, Hobbies: Religious and/or Spiritual Practice: Overall, how much support do you have from people in your life: A lot Some A little None Do you have concerns about intimate partner violence? If yes, describe your safety plan: 4 of 16

5 General Health & Medical Information Primary Care Physician (PCP): Office Phone Number: Date of last Annual Exam How would you describe your overall physical health? Excellent Good Fair Poor Have you or anyone in your family had a history of the following: Depression Anxiety Suicide Attempts Eating Disorders Violence Emotional Abuse Sexual Abuse Chronic Illness Alcoholism/Drug Addiction Current or Past Medical Conditions (more space is available on page 15): Do any of these medical conditions create mobility needs for you? If yes, please describe: Medications you are currently taking (more space is available on page 15): Do you have a Certified Service/Emotional Support Animal? Do you have concerns about your Medical Condition(s) and/or Medication? Please describe: How many days per week to you exercise? 5 of 16

6 How many meals per day to you eat? Do you snack? Do you tend to overeat or under eat? Have you or anyone ever had concerns about your exercise or eating habits? Please describe: Sleep Information On Average, how many hours of sleep to you get per night? How many hours of sleep do you need to feel rested? If you take naps, how many per day and for how long each? Are you currently experiencing any of these sleep difficulties? Can t fall asleep Frequently Awaken during the night Hard to return to sleep Awaken too early Awake Tired Oversleep Sleepwalking Nightmares Snore/Stop breathing while asleep Partners sleep difficulties impacting sleep Co-Sleep with child(ren) Please describe: Substance Use Information Caffeine: Alcohol: Amount of Caffeine consumed (Coffee, Tea, Soda, Energy Drinks, Pills, etc.) per Day or per Week Other: I do not consume caffeine Number of Alcoholic Beverages per Day or per Week 6 of 16

7 Nicotine: Marijuana: For what occasions do you drink alcoholic beverages? When you drink alcoholic beverages do you ever regret decisions you ve made or black out and not remember? If yes, please describe: I do not consume alcoholic beverages Amount of Caffeine consumed (Cigarettes, Vape/E-cigs, Chew, Gum, Patch, etc.) per Day or per Week Other: I do not consume nicotine products Use is for Recreational Purposes Medical Purposes Number of uses per Day or per Week or per Year Types of use (circle all that apply): Smoke Eatables Teas CBD-Oil Other I do not consume marijuana products Other substances used within the most recent year: Prescription Pain Medication (Vicodin, Oxycontin, Percocet, Morphine, etc.): Please describe use: Relaxers (Xanax, Benzo s, Barbs, other pills): Please describe: Body-Building Supplements, Steroids, Diet Pills Please describe: Club Drugs (Ecstasy/Molly, GHB, Dabs, Spice, Cough Syrup, etc.): Please describe: Stimulants (Methamphetamines, Speed, Crystal, Cocaine, Crack, Ritalin, etc.): Please describe: 7 of 16

8 Heroin, Inhalants, bath salts: Please describe: Hallucinogens (Mushrooms, LSD, PCP, etc.): Please describe: Other substances: Please describe: Have you or has anyone ever thought that you have a problem with alcohol or drugs? Please describe: Have you ever been to a Drug or Alcohol Treatment Program? Inpatient Outpatient When? How Long? Result: Education & Employment Information Highest level of education completed: Are you currently in an academic program? Are you planning to start? Are you: Currently Employed Employer: Currently Unemployed Stay at Home Mother Stay at Home Father Retired Annual Net Household Income: (used to determine sliding scale fee) Are you looking for work and/or to change jobs? Please explain: 8 of 16

9 Adverse Childhood Experience s Inventory Please answer the following regarding events that took place in your life prior to your 18th birthday: 1. Did a parent or other adult in the household often or very often Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? 2. Did a parent or other adult in the household often or very often Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? 3. Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? 4. Did you often or very often feel that No one in your family loved you or thought you were important or special? or Your family didn t look out for each other, feel close to each other, or support each other? 5. Did you often or very often feel that You didn t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? 6. Were your parents ever separated or divorced? 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? 8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? 9 of 16

10 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? 10. Did a household member go to prison? 10 of 16

11 0 = Not At All 1 = Somewhat 2 = Moderately 3 = A Lot 4 = Extremely Burns Depression Index (BDI) Instructions: Put a check to indicate how much you have experienced each symptom during the past week, including today. Please answer all 25 items. Thoughts and Feelings 1 Feeling sad or down in the dumps 2 Feeling unhappy or blue 3 Crying spells or tearfulness 4 Feeling discouraged 5 Feeling hopeless 6 Low self-esteem 7 Feeling worthless or inadequate 8 Guilt or Shame 9 Criticizing yourself or blaming others 10 Difficulty making decisions Activities and Personal Relationships 11 Loss of interest in family, friends or colleagues 12 Loneliness 13 Spending less time with family or friends 14 Loss of motivation 15 Loss of interest in work or other activities 16 Avoiding work or other activities 17 Loss of pleasure or satisfaction in life Physical Symptoms 18 Feeling Tired 19 Difficulty sleeping or sleeping too much 20 Decreased or increased appetite 21 Loss of interest in sex 22 Worrying about your health Suicidal Urges 23 Do you have any suicidal thoughts? 24 Would you like to end your life? 25 Do you have a plan for harming yourself? Category Totals Add up your total score for the 25 symptoms and record it here: 11 of 16

12 0 = Not At All 1 = Somewhat 2 = Moderately 3 = A Lot Burns Anxiety Index (BAI) Instructions: Put a check to indicate how much you have experienced each symptom during the past week, including today. Please answer all 25 items. Anxious Feelings 1 Anxiety, nervousness, worry, or fear 2 Feeling that things around you are strange, unreal or foggy 3 Feeling detached from all or part of your body 4 Sudden unexpected panic spells 5 Apprehension or a sense of impending doom 6 Feeling tense, stressed, uptight, or on edge Anxious Thoughts 7 Difficulty concentrating 8 Racing thoughts or having your mind jump from one thing to the next 9 Frightening fantasies or daydreams 10 Feeling that you re on the verge of losing control 11 Fears of cracking up or going crazy 12 Fears of fainting or passing out 13 Fears of physical illness or heart attacks or dying 14 Concerns about looking foolish or inadequate in front of others 15 Fears of being alone, isolated or abandoned 16 Fears of criticism or disapproval 17 Fears that something terrible is about to happen Physical Symptoms 18 Skipping or racing or pounding of the heart (sometime called palpitations) 19 Pain, pressure, or tightness in the chest 20 Tingling or numbness in the toes or fingers 21 Butterflies or discomfort in the stomach 22 Constipation or diarrhea 23 Restlessness or jumpiness 24 Tight, tense muscles 25 Sweating not brought on by heat 26 A lump in the throat 27 Trembling or shaking 28 Rubbery or jelly legs 29 Feeling dizzy, light-headed, or off balance 30 Choking or smothering sensations or difficulty breathing 31 Headaches or pains in the neck or back 32 Hot flashes or cold chills 33 Feeling tired, weak or easily exhausted Category Totals Add up your total score for the 33 symptoms and record it here: 12 of 16

13 Additional Space Provided Current or Past Medical Conditions: Medications you are currently taking: Persons living in the home with you (if none, write none): 13 of 16

14 Scoring Key for the Burns Depression Inventory Total Score Degree of Anxiety 0 5 No Depression Normal but unhappy Mild Depression Moderate Depression Severe Depression Extreme Depression Scoring Key for the Burns Anxiety Inventory Total Score Degree of Anxiety 0 4 Minimal or No Anxiety 5 10 Borderline Anxiety Mild Anxiety Moderate Anxiety Severe Anxiety Extreme Anxiety or Panic If your anxiety is above Mild Anxiety, you should act to protect yourself. 14 of 16