Murphy Toerner and Associates, Inc

Murphy Toerner and Associates, Inc

New Client Intake Form Page 1


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

  1. 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)


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?

  1. 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

  1. 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?

  1. 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)

  1. 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)



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