COUNSELING INTAKE FORM

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COUNSELING INTAKE FORM Name Age Date Full Address Home Phone Work E-mail Work History Occupation How long? If presently unemployed, describe the situation Hobbies/Avocations Any past/present military service? Branch? If you served in combat, when did you serve? Type of discharge? Reason for discharge? Education Last grade completed in school/ highest degree obtained is/was: Are you currently enrolled in school? Major/focus? Do you have any special training, skills, or certifications? Do you have any problems reading or writing? How do you learn best? What was school like for you? Describe any difficulties or problems you had/have in school: Physical History (please be accurate, medical records may need to be disclosed at some point) General Health Are you now under a doctor s care? If yes, name of doctor Reason for doctor s care Are you taking any medication? If yes, what kind? Reason for medication Last medical examination Have you ever been hospitalized for a physical illness? Describe

Have you ever been hospitalized for a mental illness? Describe Any recent major illnesses or surgeries? Any recurrent or chronic conditions? Do you smoke: Do you take drugs? If yes, what kind? Do you drink? How much? Chief Concern Please describe the main difficulty that has brought you to see me: When did you first start experiencing the problem that brought you to see me? How often does the problem occur? How long does it last? Do you currently have thoughts of harming yourself? Do you currently have thoughts of wishing you were dead? Do you currently have urges to hurt, harm, or kill someone else? If yes, whom? Have you ever seriously considered suicide or felt like harming someone else? If yes, please explain: Family Systems Information Where born How long there Ethnic ID Parents: Father alive? Where residing Relationship Mother alive? Where residing Relationship Marital Status #of marriages Spouse s name Living with a partner How long Partner s Name Children:#1 M F Age #2 M F Age #3 M F Age #4 M F Age #5 M F Age Siblings: Circle your place in the family. If a sibling is deceased, put an X through the placement number. #1 M F Age #2 M F Age #3M F Age #4 M F Age #5 M F Age #6 M F Age Family Alcoholism or Domestic Violence? Sexual Addictions or Abuse? Family history of mental health issues, even if not diagnosed? Parents divorced? If yes, what year Your age at the time If deceased, what year? Your age at the time Cause of death Any step-parents? If yes, describe when and your relationship with them If reared by someone other than your birth parents, describe the situation in some detail What family members are you closest to now? As you were growing up, what adult(s) stood out as people you could really trust? Check the statements below that describe the type of family you grew up in: overly close family no breathing room everyone was in everyone else s business no privacy boundaries not respected comfortably close family loving shared many positive experiences supportive distant, everyone did their own thing not much time spent together not a lot of support angry, lots of fighting/hostility verbal abuse and conflicts violence frightening scared to make mistakes other descriptors Has anyone in your family ever attempted or committed suicide? If yes, please explain:

Tell anything else in the space below that you think would be helpful for me, as your therapist, to know. Past Psychological/Psychiatric Treatment Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling? Please indicate which type of treatment (circle one): Inpatient Outpatient Both If yes, please indicate: When: From Whom: For What: Results: Have you ever taken medications for psychiatric or emotional problems? If yes, please indicate: When: From Whom: For What: Results: Were previous treatment experiences helpful? Why/Why not? What do you hope to achieve with therapy with me? List of Symptoms Please circle any of the following that have been bothering you lately: abused as child agoraphobia alcohol use ambition anger anxiety appetite being a parent bowel trouble career choices children compulsions compulsivity concentration confidence depression divorce drug use/abuse eating problem education energy (hi/low) extreme fatigue fears fetishes finances friends food binges guilt headaches health problems hitting/hurting others inferiority feelings insomnia intentional vomiting internet use/overuse loneliness making decisions marriage memory my thoughts nervousness nightmares obsessive thinking overweight overspending

painful thoughts panic attacks phobias relationships risk taking/endangering others sadness self-esteem separation sexual problems short temper shyness stealing sleep stress suicidal thoughts work yelling/threatening Please indicate how the issue(s) for which you are seeking treatment are affecting the following areas of your life: No Effect Little Some Much Strong N/A Effect effect effect effect Marriage / Relationship: Family: Job/school performance: Friendships: Financial situation: Physical health: Anxiety level / nerves: Mood: Eating habits: Sleeping habits: Sexual functioning: Alcohol / drug use: Ability to concentrate: Ability to control anger: Recurring/Racing Thoughts Current/Past Trauma History

Other Spiritual History Religious upbringing Present Affiliation Is this an important part of your life Why/why not Emotional Status Are you currently experiencing strong emotions? If yes, describe Do you make decisions based on your emotions? How well does that work for you? Did you have what you would consider to be childhood or other traumas? If yes, describe Thank you for taking the time to complete this and for your cooperation. I look forward to helping you accomplish the goals and healing that you desire. Tiffany Harvey, LPC, CCMHC, NCC Pelorus Counseling and Consulting, LLC

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