Microsoft Word - Adult intake form.doc



Couple Intake FormDate_____/______/______Welcome to A Better Life Counseling. Please provide the following information and answer the questions below. Please note: Information you provide here is held to the same standards and protected as confidential information. Client Name: ______________________________________________________________________ Street Address: _________________________City:_____________ State: _____ Zip: ____________ Home Phone: ( ) ______________________ May we leave a message? □ Yes □ No Cell/Other Phone: ( ) ___________________ May we leave a message? □ Yes □ No Birth Date: ______ /______ /______ Age: ________ Gender: □ Male □ Female E-mail: _________________________________________ May we email you? □ Yes □ No *Please note: Email correspondence is not considered to be a confidential medium of communication. I authorize messages to be left on voice mail/answering machine □ Yes □ No I authorize appointment reminders to be sent via: ___Text message ___E-Mail ___No Reminder Needed Marital Status: □ Never Married □ Domestic Partnership □ Married □ Separated □ Divorced □ Widowed Number of Children___________________ Number of Marriages: _________________ If you have a partner or spouse, how long have you been together? ____________If married, what year did you get married? __________If you have a partner or spouse, what is your spouse/partner’s occupation? ___________________________________If you are divorced, how long were you married? ______________________________________________________If you are widowed, when and how did your spouse die? ________________________________________________Significant Other Information First Name: ____________________________ MI: _____ Last Name: _______________________________ Age: ________ Gender: □ Male □ Female Cell Phone: ______________________ Alternate Phone: ____________________ Email: _________________________________________________________________________________ Children's Names: ___________________________________________ Age: _____________ __________________________________________ Age: _____________ __________________________________________ Age: _____________Emergency Contact: ________________________________ Phone: _________________________________ Relationship: ______________________________________________________________________________ PRESENTING PROBLEMS AND CONCERNSDescribe the problem that brought you here today: _ _ DistractibilityChange in appetiteSuspicion/paranoiaHyperactivityLack of motivationRacing thoughtsImpulsivityWithdrawal from peopleExcessive energyBoredomAnxiety/worryWide mood swingsPoor memory/confusionPanic attacksSleep problemsSeasonal mood changesFear away from homeNightmaresSadness/depressionSocial discomfortEating problemsLoss of pleasure/interestObsessive thoughtsGambling problemsHopelessnessCompulsive behaviorComputer addictionThoughts of deathAggression/fightsProblems with pornographySelf-harm behaviorsFrequent argumentsParenting problemsCrying spellsIrritability/angerSexual problemsLonelinessHomicidal thoughtsRelationship problemsLow self - worthFlashbacksWork/school problemsGuilt/shameHearing voicesAlcohol/drug useFatigueVisual hallucinationsRecurring, disturbing memoriesOther: _ _ _ _ __ Please check all of the behaviors and symptoms that you consider problematic:Are your problems affecting any of the following? Handling everyday tasksSelf esteemRelationshipsHygieneWork/SchoolHousingLegal mattersFinancesRecreational activitiesSexual activityHealthYesNoHave you ever had thoughts, made statements, or attempted to hurt yourself? If yes,please describe: _ _ _ _ YesNoHave you ever had thoughts, made statements, or attempted to hurt someone else? If yes, please describe: _ _ _ _ YesNoHave you recently been physically hurt or threatened by someone else? If yes,please describe: _ _ _ _ YesNoHave you gambled in the past 6 months? If yes, let us know the followingYesNo Have you ever felt the need to bet more and more money?YesNo Have you ever had to lie to people important to you about how much you gambled?Therapist Notes:FAMILY AND DEVELOPMENTAL HISTORYRelationshipNameAgeQuality of RelationshipMotherFatherStepmotherStepfatherSiblingsSpouse/partnerChildrenFamily Mental Health ProblemsWho?HyperactivitySexually AbusedDepressionManic DepressionSuicideAnxietyPanic AttacksObsessive-CompulsiveAnger/AbusiveSchizophreniaEating DisorderAlcohol AbuseDrug Abuse Parents legally married or living togetherMother remarried:Number of times Parents temporarily separatedFather remarried:Number of times Parents divorced or permanently separatedPlease check if you have experienced any of the following types of trauma or loss: Emotional abuseNeglectLived in a foster homeSexual abuseViolence in the homeMultiple family movesPhysical abuseCrime victimHomelessnessParent substance abuseParent illnessLoss of a loved oneTeen pregnancyPlaced a child for adoptionFinancial problemsTherapist Notes:Init:PREVIOUS MENTAL HEALTH TREATMENTYes NoType of TreatmentWhen? Provider/ProgramReason for TreatmentOutpatient CounselingMedication (mental health)Psychiatric HospitalizationDrug/Alcohol TreatmentSelf-help/Support GroupsTherapist Notes:Init:SUBSTANCE USE HISTORYSubstance TypeCurrent Use (last 6 months)Past UseYNFrequencyAmountYNFrequencyAmountTobaccoCaffeineAlcoholMarijuanaCocaine/crackEcstasyHeroinInhalantsMethamphetaminesPain KillersPCP/LSDSteroidsTranquilizersYesNoHave you had withdrawal symptoms when trying to stop using any substances? If yes, please describe: _ _ YesNoHave you ever had problems with work, relationships, health, the law, etc. due to your substance use? If yes, please describe: _ _ Therapist Notes:Init:MEDICAL INFORMATIONDate of last physical exam: Have you experienced any of the following medical conditions during your lifetime? AllergiesAsthmaHeadachesStomach achesChronic painSurgerySerious accidentHead injuryDizziness/faintingMeningitisSeizuresVision problemsHigh feversDiabetesHearing problemsMiscarriageSexually transmitted diseaseAbortionSleep disorderOther: _ Please list any CURRENT health concerns: _ _ Current prescription medications:NoneMedicationDosageDate First PrescribedPrescribed ByCurrent over-the-counter medications (including vitamins, herbal remedies, etc.): _ _ _ _ __ Allergies and/or adverse reactions to medications:NoneIf yes, please list: _ _ _ _ Therapist Notes:Init:INTERPERSONAL/SOCIAL/CULTURAL INFORMATIONPlease describe your social support network (check all that apply):FamilyNeighborsFriendsStudentsCo-workersSupport/Self-Help Group Community GroupReligious/Spiritual Center (which one? )To which cultural or ethnic group do you belong? _ _ If you are experiencing any difficulties due to cultural or ethnic issues, please describe: _ _ _ _ __How important are spiritual matters to you?Not at allLittleSomewhatVery muchYesNoWould you like spiritual/religious beliefs to be incorporated into your counseling?Please describe your strengths, skills, and talents? __ _ _ _ _ _ __ Describe any special areas of interest or hobbies (art, books, physical fitness, etc.): _ _ _ __Therapist Notes:Init:EmploymentMISCELLANEOUS INFORMATIONEmployer: _ _ Position: _ _ _ Length of time in this position: _ Job Duties: _ _ Stress level of this position: LowMediumHighOther jobs you have held: _ _ _ __EducationYesNoAre you currently attending school? High School Graduate?OrGED?Year _Associate’s DegreeYear _Major area of study _ _Undergraduate DegreeYear _Major area of study _ _Graduate DegreeYear _Major area of study _ _Military ServiceYesNoHave you been/are you currently in the military? (If no, skip remainder of this section)Branch Date of Discharge __ Type of Discharge _ _ Rank YesNoWere you in combat?LegalYesNoHave you ever been convicted of a misdemeanor or felony? If yes, please explain _ _ _ YesNoAre you currently involved in any divorce or child custody proceedings? If yes, pleaseexplain _ _ Therapist Notes:Init:What do you hope to accomplish through counseling? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ What have you already done to deal with the difficulties? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ What are your biggest strengths as a couple? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship. 1 2 3 4 5 6 7 8 9 10 (extremely unhappy) (extremely happy) Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Have you received prior couples counseling related to any of the above problems? □ Yes □ No If yes, when: _____________________________ Where: _______________________________ By whom: _______________________________ Length of treatment: _____________________ Problems treated: __________________________________________________________________ _________________________________________________________________________________ What was the outcome (check one)? □ Very successful □ Somewhat successful □ Stayed the same □ Somewhat worse □ Much worse Have either you or your partner been in individual counseling before? □ Yes □ No If so, give a brief summary of concerns that you addressed. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Do either you or your partner drink alcohol to intoxication or take drugs to intoxication? If yes for either, who, how often and what drugs or alcohol? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Have either you or your partner struck, physically restrained, used violence against or injured the other person? If yes for either, who, how often and what happened. __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems? If yes, who? ___Me ___Partner ___Both of us If married, have either you or your partner consulted with a lawyer about divorce? If yes, who? ___Me ___Partner ___Both of us Do you perceive that either you or your partner has withdrawn from the relationship? If yes, which of you has withdrawn? ___Me ___Partner ___Both of us How frequently have you had sexual relations during the last month? ________times How enjoyable is your sexual relationship? (Circle one) 1 2 3 4 5 6 7 8 9 10 (extremely unpleasant) (extremely pleasant) How satisfied are you with the frequency of your sexual relations? (Circle one) 1 2 3 4 5 6 7 8 9 10 (extremely unsatisfied) (extremely satisfied) What is your current level of stress (overall)? (Circle one) 1 2 3 4 5 6 7 8 9 10 (no stress) (high stress) What is your current level of stress (in the relationship)? (Circle one) 1 2 3 4 5 6 7 8 9 10 (no stress) (high stress) Rank order the top three concerns that you have in your relationship with your partner (1 being the most problematic): 1. _____________________________________________________________________ 2. _____________________________________________________________________ 3. _____________________________________________________________________Therapist Notes:Init:By signing below you certify that the information given is correct to the best of your knowledge. ___________________________________ __________________________________ Client’s signature Date ................
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