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

Similar documents
Health and Social Information 1. How is your physical health at present? (Please circle) Poor Unsatisfactory Satisfactory Good Very good

SANDSTONE PSYCHOLOGICAL PRACTICE

PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT

ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.

CERTIFICATION AND AUTHORIZATION (if applicable)

Demographic Information Form

Life, Family and Relationship Questionnaire

Client Information Form

SECTION 2: CURRENT CONCERNS Briefly describe the current concerns you would like to discuss with your counselor:

Demographic Information Form

Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:

Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC

C O U P L E S I N T A K E F O R M

Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:

SAMPLE. Date of Birth: Age: Gender: Woman: Man: Transgender: Transman: Transwoman: Gender Nonconforming: Other:

Juniata College Health & Wellness Counseling Center INITIAL ASSESSMENT

CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):

Name:, Sex:, Age: Ethnicity, Race. Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( )

JILL L. KOFENDER, PHD, PLLC. Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE. Client s Name Today s Date Gender Age Birthdate

A New Tomorrow Behavioral Health Services

Eliada Assessment Center Application for Services

Gishela Satarino, MA, LPC-S 6750 Hillcrest Plaza Drive, #203 Dallas, TX History Form for Counseling Services

CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:

GeMS Young Adult Self-Report Questionnaire

Name Age Relationship to patient

Katarina R. Mansir, Psy.D. Licensed Psychologist PSY25417 (858) Name: Date: Presenting Concerns

Journey to Truth Counseling

MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION

Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:

MINDFUL WELLNESS CENTER, PLLC

Adult Information Form Page 1

Initial Clinical History and Physical Form

Client s Name: Street City State Zip. Home Phone Work Phone Cell Phone. Student: Full-time Part-time Grade School. Current or past Education:

GARDEN STATE SLEEP CENTER REGISTRATION FORM PATIENT INFORMATION:

CLIENT INTAKE FORM. Please describe your main reason(s) for seeking services at this time?

ADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):

Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F

Adult Information Form

Child/ Adolescent Questionnaire

ADULT INFORMATION SHEET

Client Intake History

Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results

Associates of Behavioral Health Northwest CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT

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

Christina Pucel Counseling 416 W. Main St Monongahela, PA /

PERSONAL HISTORY What are your strengths? (i.e. skills, positive qualities or characteristics) Hobbies/Extracurricular Activities (Please list): ETHNI

Case Number Application page 1. The AIDS Foundation of Western Massachusetts, Inc. P.O. Box 86 Chicopee, MA 01014

Substance Use Disorder Intake/Assessment Form

A HEALING ALTERNATIVE COUNELING AND WELLNESS CENTER, LLC

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:

10. Has your child ever been diagnosed with an unexplained seizure disorder or exercise-induced asthma?

Crawford consulting and mental health services, inc ADOLESCENT PSYCHOSOCIAL ASSESSMENT

Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION

Dr. Charles E. Copeland, DC Highland Chiropractic

Choice Counseling Associates

CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake)

COUNSELING INTAKE FORM

Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:

Name: Birthdate: Gender: Address: Phone: (Home) (Work) (Cell) Highest Education Attended: Occupation: Place of Employment:

Amanda G. Johnson, LPC

Psychiatric Residential Treatment Facility Referral

Application and History for Adult

Chiropractic Case History/Patient Information

Dear Prospective Volunteers,

Address: Spouse/Partner Name: Phone: Address:

Crawford consulting and mental health services, inc ADULT PSYCHOSOCIAL ASSESSMENT

JACKSONVILLE SPEECH & HEARING CENTER PATIENT INFORMATION FORM PEDIATRIC (CHILD) - AUDIOLOGY Please Print

Fairview Counseling Centers Adult Intake Form

Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA Phone: (707) FAX: (707)

CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:

Lake Psychological Services, LLC

Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:

Last Name First Middle Date of Birth Age. Residence Address City State Zip Code

Please check all the behaviors and symptoms that you consider problematic:

Evergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!

CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:

Northside Mental Health Center Intake Questionnaire

PATIENT INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT

ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION

2550 Middle Road, Suite 316 Bettendorf, Iowa Adult Intake Form

Center for Transformative Counseling, Inc. 801 Georgia Street Key West, FL

Diana Valdez, PhD, LPC

Lions Sight & Hearing Foundation Phone: Fax: Hearing Aid: Request for assistance

New Client Information. address: Date of Birth:

MINOR CLIENT HISTORY

Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone

Steve Barns & Associates The Counseling Center of Denton Bible Church Christian Counseling Services Individual, Marriage, & Family

APPLICATION FOR SERVICES

Client: Date of Birth: Date of Report: MENTAL STATUS EXAMINATION REPORT 1. Identifying Information

Application for Patient

NC Hair Loss Center 1418 Aversboro Rd Suite 103 Garner, NC Phone

COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):

CBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:

Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No

We Believe that you are Designed to be Extraordinary. (Office Use) Care Provider: Name: Date of birth (MM/DD/YY): Apt# City: Prov: PC:

Rise Chiropractic 239 S. French Broad Ave Asheville, NC

Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx

Atlanta Psychological Services

DIRECTIONS FOR USING THE MENTAL HEALTH ADVANCE DIRECTIVE POWER OF ATTORNEY FORM

Transcription:

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

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

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

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

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

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

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

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

THERAPIST NOTES: CHIEF COMPLAINT HISTORY: GOALS: 9

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback