Johanna Wendell, LPC
Intake Form
NameAppointmentDate BirthDate Age Sex Religion MaritalStatus Race Children Address City State Zip Home Phone# Cell #
Who areyoucurrentlylivingwith?
Referral source______
MAINPURPOSE OFTHE CONSULTATION(Pleasegivea brief summaryofthe main problems)
WHY DID YOU SEEKTHE EVALUATION AT THISTIME?What areyourgoals in beinghere?
PRIOR ATTEMPTS TO CORRECTPROBLEMS/PRIORPSYCHIATRIC HISTORY
(Please includecontact with other professionals,medications,types oftreatment, etc.)
MEDICALHISTORY
Currentmedicalproblems/medications:
Currentsupplements/vitamins/herbs:
Pastmedicalproblems/medications:
CURRENTLIFESTRESSES(include anythingthat is currentlystressfulforyou,examplesincluderelationships, job, school,finances,children)
Coping Resources (social supports, hobbies, exercise, nutrition, etc) ______
Sleepbehavior: sleepwalking,nightmares, recurrent dreams,current problems (gettingup,goingtobed)
SchoolHistory:Lastgrade completed Last schoolattended Averagegradesreceived Specificlearningdisabilities Learningstrengths Anybehavior problems in school? What haveteacherssaidaboutyou
Employment History:(summarizejobsyou've had, list most favorite andleastfavorite)
Anywork-relatedproblems? What wouldyour employers or supervisorssayaboutyou?
MilitaryHistory?
Ever AnyLegalProblems?
Sexualhistory: (answeronlyasmuchasyoufeelcomfortable)
Age at thetimeof first sexual experience:Number ofsexual partners:
Anyhistoryofsexuallytransmitteddisease?History of abortion? Historyof sexual abuse,molestation or rape? Current sexual problems?
Domestic Violence:
Have you ever been the victim of domestic violence? ______If yes, please explain:
Have you ever been the perpetrator of domestic violence? ______If yes, please explain:
Alcohol and DrugHistory: (Please list age startedandtypes ofsubstances usedthrough theyearsandanycurrent usage. Also,describe how eachof these substancesmadeyoufeel;whatbenefityougot from them.).These includealcohol(hardliquor,beer,wine),marijuana orhash, prescription tranquilizers or sleepingpills,inhalants(glue,gasoline,cleaningfluids,etc.),cocaine orcrack,amphetamines or crankor ice, steroids, opiates(heroin,codeine, morphineorother pain killers),barbiturates,hallucinatingdrugs(LSD, mescaline,mushrooms), PCP.
Everexperiencewithdrawalsymptomsfrom alcohol or drugs? Hasanyone told you they thoughtyouhad a problem withdrugsoralcohol? Haveyou ever felt guilty aboutyour drug or alcohol use? Haveyou ever felt annoyedwhen someonetalked to youaboutyour drug oralcoholuse? Haveyou ever used drugs or alcoholfirst thingin the morning?
Nicotine use per day, past andpresent,(nicotine isincigarettes,cigars,tobaccochew)
FAMILY HISTORY
FamilyStructure (who lives inyourcurrenthousehold,pleasegiverelationship to each):
Current Marital or RelationshipSatisfaction
Significant DevelopmentalEvents(include marriages,separations,divorces,deaths,traumaticevents, losses,abuse,etc.)
History ofPast Marriages
NaturalMother's History: ageoutsidework School:highest grade completed
Learningproblems
Behavior problems
Marriages MedicalProblems Childhood atmosphere (familyposition, abuse,illnesses,etc)
Hasmother ever soughtpsychiatric treatment? YesNoIfyes,forwhatpurpose?
Mother'salcohol/drugusehistory:
NaturalFather's History: ageoutsidework
School:highest grade completed
Learningproblems
Behavior problems
Marriages MedicalProblems Childhood atmosphere (familyposition, abuse,illnesses,etc)
Hasfather ever soughtpsychiatric treatment? YesNoIfyes, forwhatpurpose?
Father'salcohol/drug use history
Siblings(names,ages, problems, strengths,relationship to patient)
Children(names,ages,problems,strengths)
Cultural/Ethnic Background
Describe yourrelationshipswithfriends
Describe yourself
Describe your strengths