Murphy Toerner and Associates, Inc
New Client Intake Form Page 1
CAMBRE COUNSELING AND WELLNESS, LLC
Lindsay Cambre, LPC, NCC, NCSC
Please complete prior to first session. You can choose to email this completed form back to Lindsay Cambre, LPC PRIOR to first session or you can bring it to your scheduled appointment.
I. Personal Information
Name:_ Date: Age Date of Birth
Address:_City:State: Zip
Cell Phone: Work Home
May I leave a message at numbers listed?Yes No May I email you? Yes No
Have you ever been to a counselor before? Yes No
If yes, reason for termination:
Who referred you to this office?
Who to contact in case of emergency? Relationship: Phone:
Do you currently have health insurance? Yes No
Insurance Provider Insurance Plan Name
Subscriber’s Contract Number Subscriber’s Policy Group Number or Name
II. History of the Presenting Problems or Complaint
State the nature of the problem; primary need for appointment:
III. Medical History
Rate your physical health: Very Good Good Average Declining Poor
List any major health concerns for which you have received treatment in the last 2 years, including any hospitalizations or procedures.
Please list any current medical conditions (high blood pressure, asthma, chronic pain, etc.)
Please list any medications and/or vitamins you are currently taking, even if they were not prescribed for you.
Name Dosage/How Often Reason Taken How long taken
Please list any medications that you have previously taken for anxiety, depression, or related types of problems.
Name Dosage/How Often Reason Taken How Long Taken
Name of Primary Care Doctor: Address: Phone: Date of last exam
Have you ever sustained a head injury, experienced seizures/convulsions, or loss of consciousness? If yes to any condition, please describe:
IV. Daily Wellness
- Alcohol/Drug UseYESNO
Do you drink alcohol more than once per week?
If yes, how often
Have you ever felt the need to cut down on your drinking?
Have you ever felt judged or annoyed by criticism of your drinking?
How much beer, wine, or liquor do you consume weekly (average)?
Have you ever drank and loss consciousness?
How often do you engage in recreational drug use? (circle one)
DAILY WEEKLY MONTHLY INFREQUENTLY NEVER
What drugs have you used in the past, including legal marijuana and over-the counter products? _
Do you smoke or use tobacco products? If yes, how often?
- Caffeine Usage
Please specify the amount of any of the following products with caffeine that you drink or use within a typical 24 hour day.
Cola Brewed Coffee Instant Coffee Instant Tea Brewed Tea Chocolate Beverage Chocolate Candy Energy drink Other
- Sleep Patterns/Diet/Exercise
How do you sleep at night?
Describe your typical diet:
Any present or past difficulties with eating or appetite?
Do you exercise? If so, how often?
- Judicial Concerns
Have you ever been arrested or incarcerated? YES NO If yes, list dates and charges
If you have been appointed by court/parole officer to have this appointment, please list current/pending charges, current Attorney’s name, and pending court date (if applicable)
- Religious Preferences
Do you consider yourself to be religious or spiritual? YES NO
Any spiritual concerns with counseling?
Current religious denomination
Level of involvementNoneIrregularActive
How important is religion in your life?
V. Family
List the members of your family or others in your home:
Name Age/DOB Relationship Occupation
Ex-spouses, Children, Significant friends outside the home:
Name Age/DOB Relationship Occupation
Current Living Situation (check as needed)
SINGLEMARRIEDLIVING TOGETHER
SEPERATEDDIVORCEDWIDOWED
If you are in a current relationship, how long? _
If yes, on a scale from 1-10 (10 being the best), how would you rate the relationship?
VI. Employment
Are you currently employed and if yes, where?
Years with company? Title of position:
Are you currently feeling satisfied with your employment?
VII. EducationYESNO
Do you experience any learning difficulties?
Did you fail any grade levels?
If so, what grades/subjects:
Were you often in trouble at school? Suspension/Expulsion
If so, describe:
What is your highest level of education? Are you currently attending school? Where?
IIX. Crisis Information
If you have had thoughts of suicide, either recently or in your past, please share a brief explanation?
Do you have a history of anger or impulse control problems? Yes No
Have you experienced the death of a loved one within the last five (5) years? Yes No
Have you experienced any other significant losses within the last five (5) years? Yes No
If Yes, please explain
Have any of your family members ever received psychiatric or psychological help or counseling of any kind before? YesNo If Yes, please explain:
Do any of your family members have a history of mental illness? Yes No
If Yes, please explain whom and the nature of the illness.
How willing are you to let go of old ideas and behaviors so you can learn new habits and actions to change and enhance your life experience?
Anything else you would like me to know? Please share below.
** If you are completing and emailing back to Lindsay Cambre, LPC prior to appointment, a copy will be printed for you to sign at first session **
Client Signature:______
Date: ______
Located in Lutcher & Prairieville Louisiana
~ Phone 225/306-3177 ~ Fax 225/869-9143