Adult Intake Form - Please Print

Name: / Date:
Date of Birth: / Age: / Sex: / Female / Male
Address: / Apartment:
City: / State: / Zip Code:
Home Phone: / Work Phone:
Cell: / E-mail Address:
Okay to leave messages on(check all that apply): / Home Phone / Cell Phone / Work Phone / E-mail
Presenting problem
Describe the main problem that brought you here today:
Current Symptom Check list (check all that apply and rate the intensity of each symptom checked)
None / = / Symptoms not present at this time
Mild / = / Impacts quality of life, but no significant impairment of day-to day functioning
Moderate / = / Significant impact on quality of life and/or day to day functioning
Severe / = / Profound impact on quality of life and/or day to day functioning
Symptom / None / Mild / Moderate / Severe / Note
Depressed Mood
Appetite Changes
Sleeping changes
Feelings of Guilt
Fatigue/low energy
Poor Concentration
Irritability/Anger
Substance Abuse
Anxiety
Hopelessness
Physical Complaints
Social Isolation
Worthlessness
Loss of Pleasure or interest in hobbies
Weight loss
Weight gain
Intense Crying
Recurring thoughts/images
Feelings of Panic
Loneliness
Memory impairments
Disorganized thoughts
Family Information:
Mother‘s Name / Age: / Living: / Yes / No
Father‘s Name / Age: / Living: / Yes / No
Spouse‘s Name / Age: / Living: / Yes / No
1st Child’s Name / Age: / Living: / Yes / No
2nd Child’s Name / Age: / Living: / Yes / No
3rd Child’s Name / Age: / Living: / Yes / No
4th Child’s Name / Age: / Living: / Yes / No
Present Marital Status : / Never married / Engaged / Widowed / Separated / Divorced
Divorced and remarried / Widowed and remarried / Married / Number of marriages:
Other (specify):
Is there a history of child abuse? / Yes / No / If so, when did this abuse occur?
Date
If so, which type? / Physical / Emotional / Verbal / Sexual / Neglect
If so, the abuse was as a: / Victim / Perpetrator / Who victimized you?
Any current or history of being a sexual predator? / No / Current / Past history
Social Relationships
Check how you generally get along with other people: (Check all that apply)
Affectionate / Aggressive / Avoidant / Friendly / Leader / Outgoing / Follower
Submissive / Fight/argue often / Shy/withdrawn / Other
Describe your support system: / Very Close / Close / Casual / Not Close / Distant / Estranged
My support system is Adequate? / No / Yes
Cultural/Ethnic
To which Cultural or Ethnic Group do you belong? / Caucasian / African-American/Black / Asian
Native American / Middle Eastern / Hispanic / Cuban / Mexican / Puerto Rican
Spanish Culture of Origin / South or Central American / Other (specify):
Any cultural/ethnic information that would be helpful for your counselor to know/understand? (describe below)
Spiritual/Religious
How important is your spiritual/religious beliefs?
Very important / Somewhat important / Not important / Not spiritual/religious at all
Are you affiliated with a spiritual/religious group? / Yes / No / If so, what?
If so, do you regularly participate with this group? / Yes / No / If so, how often?
Were you raised within a spiritual or religious group? / Yes / No / If so, what?
Are their any spiritual/religious issues that are bother you that you would like to discuss? (describe below)
What role does faith/prayer have in your everyday life?
How has your faith been a part or affected by this situation?
Legal
Are you currently involved in any active cases (traffic, civil, criminal)? / Yes / No
If yes, please describe and indicate the court and hearing/trial dates and charges:
Are you currently on probation or parole? / Yes / No
Past: Have you had (P all that apply) / Criminal Involvement / DWI, DUI, etc: / Civil Involvement
If you checked any of the above, please fill in the following information.
Charges / Date / Where (city) / Results
Education
Fill in all that apply / Are you currently enrolled in school? / Yes / No
High School Graduate / When? / Graduated? / Yes / No / GED? / Yes / No
College / When? / Graduated? / Yes / No / Degree:
Graduate / When? / Graduated? / Yes / No / Degree:
Post Graduate / When? / Graduated? / Yes / No / Degree:
Other training:
Special Circumstances (e.g. Learning Disabilities, gifted): / Yes / No / Explain:
Employment
Currently: / Full-time / Part-time / Temporary / Retired / Laid-off / Disabled
Student / Other:
Employer: / Title:
Military
Military experience? / Yes / No / Combat experience? / Yes / No
If so, where?
Branch of Military: / Army / Navy / Air Force / Marines / Coast Guard
Date of Discharge: / Type of Discharge:
Years of Service: / Rank at Discharge:
Medical Health
Describe your health status: / Excellent / Good / Fair / Poor
List any health issues you have (i.e. high blood pressure, diabetic, etc):
List any prescription drugs you are currently taking:
Drug’s name / Dosage (mg/daily) / Dates taken / Purpose
Primary Care Physician Information: / Doctor’s Name:
Address / City / Zip Code / Phone Number
Date of last Visit: / Reason:
Date of last Physical: / Results:
Date of last Surgery: / Reason:
Upcoming Surgery: / No / Yes / When? / Reason:
Check if you have noticed any of the following changes: / Physical Activity Levels / Sleeping patterns
Eating Patterns / Mood / Behavior / Weight / Energy Level / Enjoyment of pleasure activities
Other:
Describe the changes you checked:
Are you currently taking illegal drugs? / No / Yes / If so, what?
If so, how long have you used this drug? / Frequency of use? / How much?
Are you drinking Alcohol? / No / Yes / Frequency of use?
If so, how long have you used alcohol? / How much?
Describe when and where you typically uses these substances:
Describe any changes in your use patterns:
Describe how your use has affected your family or friends (what are their perceptions of your use):
Have you ever wanted to stop but feel you cannot? / No / Yes
Counseling/Mental Health
Have you ever received counseling before? / No / Yes / If so, why?
Have you ever been diagnosed with a mental disorder? / No / Yes / If so, what was that diagnosis (specify):
With whom? / When?
Have you ever been hospitalized for psychological reasons? / No / Yes / If so, explain.
Have you ever had past thoughts of seriously hurting or killing yourself? / No / Yes / If so, explain.
Have you ever had a suicide attempt? / No / Yes / If so, explain.
How have you coped with pervious life pains and/or troubles?
List your personal Strengths:
1.
2.
3.
4.
What are the issues that you would like to work on in counseling?
1.
2.
3.
4.
What are your Goals for Counseling?
1.
2.
3.
4.
Concurrent stressors/Crisis (check all that apply)
Divorce/Separation / Date: / Limited Finances / Date:
Illness/injury / Date: / Other recent deaths / Date:
New home or job / Date: / Other / Date:
Are you currently thinking about hurting or killing yourself? / No / Yes
If so, how? / Do you have the means to carry it out? / No / Yes
How satisfied are you with your life these days? (circle one)
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Not at all / Somewhat satisfied / Very Satisfied
Rate the intensity of your emotional pain today? (Circle 1)
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
No pain at all / Extreme Pain/intolerable
Are you currently seeing another counselor and/or Psychiatrist or Psychologist? / No / Yes
If yes, who? / A counselor / A Psychiatrist / A Psychologist
Address / City / Zip / Phone
Emergency Contact information Section
1st Emergency call: / Relationship:
Address: / Apartment:
City: / Zip: / Home Phone:
Cell: / Work Phone:
Okay to leave messages on(check all that apply): / Home Phone / Cell Phone / Work Phone / E-mail
2nd Emergency call: / Relationship:
Address: / Apartment:
City: / Zip: / Home Phone:
Cell: / Work Phone:
Okay to leave messages on(check all that apply): / Home Phone / Cell Phone / Work Phone / E-mail
Anything else you would like your counselor to know:
Signature / Date