ELLIS COUNSELING, L.L.C.
1820 Glynwood Drive, Suite B
Prattville, Alabama 36066
Phone: 334-358-2455
Fax: 334-491-2456
CONFIDENTIAL INTAKE INFORMATION
General Information
Client(s) Name______Date______
Parent/Guardian Name ( if applicable)______
Client’s Date of Birth______Client’s Gender: Male Female
Address______Work Phone______
City______State______Zip_____Home Phone______
SSN______Employer______
Employment Position(s) of parents (if client is minor child)
Father______Mother______
Education/Training or School and Grade of client______
Spouse’s Name______Spouse’s SSN______
Spouse’s Employer______Spouse’s Position______
Spouse’s Education/Training______
No. of Marriages______No. of Children______
Child’s/Siblings Name______Birthday______
Child’s/Sibling’s Name______Birthday______
Child’s/Sibling’s Name______Birthday______
Child’s/Sibling’s Name______Birthday______
Emergency Contact Person______Address______Phone#______
(CONFIDENTIAL INTAKE page 2)
Insurance Information (If applicable)
Insured’s Name: ______
LastFirstMiddle
Insured’s Address: ______
Street
______
CityStateZip
Insured’s Phone Number:( ) ______
Insured’s ID Number: ______
Insured’s Policy Group or FECA #: ______Insured’s Date of Birth:______
Insured’s Gender: (Circle One) Male Female
Insured’s Employer Name:______
Insurance Plan Name or Program:______
Is there any other Health Benefit Plan (Circle One) Yes No
If Yes, Other Insured’s Name: (Last, First, Middle) ______
Insured’s Address______
StreetCity StateZip
Insured’s Phone #______
Other Insured’s Policy#______Group #______
Other Insured’s Date of Birth:______
Other Insured’s Gender: (Circle One) Male Female
Employer’s Name or School Name:______
Insurance Plan Name or Program Name:______
(confidential page 3)
Physical Health Information
Short Statement Regarding Current Physical Health of client(s) ______
List below any physical health problems:
- Date of Onset
- Date of Onset
- Date of Onset
- Date of Onset
- Date of Onset
Mental Health Information
Date of Most Recent Illness/Symptom of issue for which you are seeking counseling: ______
Have you previously had the same or similar symptom(s)? Yes____ No____
If yes, give first date: ______
If unable to return to work, give date:______
Hospitalization Dates Due to Current Illness/Symptoms:______
Is Current Condition Due to any of the following?
Auto Accidentyes ____ no____
Other Accidentyes ____ no____
Employmentyes ____ no____
Name of Referring Provider:______
If not referred by provider, how did you learn about us?______
______
Name of Primary Physician______Phone#______
Medications______Dosage______Dosage______Dosage______Dosage______
Client’s Family Mental Health Background:
Is there any history of the following in the client’s family? (Family includes parents, siblings, grandparents, cousins)
DepressionYes ____No____ Family Member with Condition______
AnxietyYes ____No____ Family Member with Condition______
Bi-polarYes ____No____ Family Member with Condition______
SchizophreniaYes ____No____ Family Member with Condition______
Drug Abuse Yes ____No____ Family Member with Condition______
AlcoholismYes ____No____ Family Member with Condition______
OtherYes ____No____ Family Member with Condition______
Are you currently seeing a counselor, psychologist, psychiatrist or other helping professional? ___yes ___no
If so, who?______
If you have ever been hospitalized, please explain.______
______
Are you currently involved in any legal actions? If so, please explain______
______
Is there a recent life crisis that has prompted you to seek counseling at this time?
___yes no___ If so, please describe______
I understand I am financially responsible for payment of charges at the time services are rendered. If insurance is filed, I also understand that I will be responsible for any fees not paid by theinsurance provider. I further acknowledge that I am voluntarily consenting to counseling and that no guarantees have been made as to the results of counseling.
Signature______Date______