Intake Form

Feel free to review the two client forms and contact me with any questions. If we have agreed to move forward with therapy, please complete intake form below and the client contract here and we can schedule our first session together.

CONFIDENTIAL – ADULT COUNSELING INTAKE FORM DATE

PATIENT NAME AND IDENTIFYING INFORMATION:

Full Name

SSN

DOB

Last Name

First Name

Middle Initial

Nickname

DOB

Age

Preferred Pronouns/Gender

Current Marital Status

Spouse’s/Partner's Name

Age

Years Married/Together

Names of Children and/or Step Children and ages

Presently living with

Who referred you or how did you hear about me?

OCCUPATIONAL /EDUCATIONAL INFORMATION:

Occupation

Employer

How long?

If Currently a Student: What school?

Field of Study?

Student Occupation

Last year of school completed

College

Military Service (including branch of service and dates)

REASONS FOR SEEKING HELP:

What concerns have led you to pursue counseling?

When did this begin to be a problem for you?

Please rate the severity of your concerns

What do you hope to gain from counseling?

If other people are involved in your present problem, who are they and how could they help improve the situation?

MEDICAL/HEALTH INFORMATION:

How would you rate your current health?

Date of last physical exam

Physician

Are you currently experiencing any physical problems? (e.g. headaches, body aches, stomach problems):

If yes, please explain

Describe any physical problem you or a member in your household have which require medical or physical care:

Have you ever had surgery? If yes, for what reason?

Are there chemical substance abuse issues in your family? Y/N, If so who?

If clean/sober, for what length of time?

Have you ever been hospitalized for mental illness or substance abuse?

If yes, for what specific reason and where?

Have you ever participated in counseling before? Y/N, If yes, when and why?

Name of Therapist

Any other information that you feel is important to share that is not covered

ADDRESS AND CONTACT INFORMATION:

Mailing Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Second cell phone and name of who it belongs to

Client email address

Emergency Contact: Name

Relationship

Phone

For confidentiality, to confirm and/or change appointments, may I contact you at:Check all that apply

Home

Work

Cell

Please list preferred days/times for your appointment availability

RELIGIOUS BACKGROUND:

Religious Affiliation

Active or Inactive?

Do you attend a local church? Y/N, If yes, name of church

How significant is your religion to your everyday life?

Get in Touch!

(724) 866-3166

ash6510@gmail.com

Psychology Today

Get in Touch!

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