CLIENT INTAKE FORM



CLIENT INTAKE FORMClient Contact InformationDate of First Session _______________Name:___________________________________Email Address: ___________________________________Cell Phone: ________________________________Alternative Phone: ________________________________Home Address: _____________________________________________________________________________Emergency ContactName:_____________________________Relationship:__________________Phone:_________________Address: __________________________________________________________________________________Client InformationHow did you hear about Catholic Counseling Service: ______________________________________________Date of Birth: ______________________________ Employment:____________________________________ Check the highest level of schooling that you have completed: □ Elementary School □ High School □ College □ Post College □ Trade School □ GED □ Other ___________Have you served in the military: □ Yes □ No If yes, what branch: ______________________________ How many years of service: ___________________Briefly describe your work history:________________________________________________________________________________________________________________________________________________________Have you ever been in trouble with the law: □ Yes □ NoIf yes, please explain: ________________________________________________________________________Are you currently involved in legal problems: □ Yes □ NoIf yes: □ Divorce/Separation □ Custody □ Lawsuit □ Parole □ Probation □ Other: _______________Have you been a victim or perpetrator of abuse: □ Yes □ NoIf victim:□ Sexual □ Emotional □ Physical If perpetrator:□ Sexual □ Emotional □ PhysicalCurrent Family & Family of Origin HistoryMarital Status: □ Single □ Committed relationship □ Married □ Separated □ Divorced □ WidowedHow many year(s) have you been in your current marriage or relationship: _____________Were you previously married: □Yes □ NoIf yes, how many times: ________________Was your spouse/partner previously married: □Yes □ NoIf yes, how many times: ________________Are you currently sexually active: □ Yes □ No Do you have trouble in your relationships with others: □ Yes □ NoPlease list your children’s name(s), age(s), and occupation(s) including “student”:NameAge Occupation__________________________ ________ ________________________________________________ ________ ________________________________________________ ________ ________________________________________________ ________ ______________________Please list additional person(s) living with you:Name Age Relationship Occupation__________________________ ________ ________________________________________________________________________ ________ ________________________________________________________________________ ________ ________________________________________________________________________ ________ ______________________________________________Please list below any physical or emotional health problems that members of your family are currently suffering or suffered in the past—Include relevant extended family such as parents: ________________________________________________________________________________________________________________________________________________________________________________________________________Is there a family history of mental illness, attention problems, or addiction? □ Yes □ No If yes, please explain:________________________________________________________________________Medical HistoryAre you currently under treatment by a psychiatrist: □ Yes □ NoIf yes, Psychiatrist’s Name: ________________________ Psychiatrist’s Phone Number: ___________________Would you sign a release of information to coordinate care with them: □ Yes □ NoHave you ever been diagnosed with a mental disorder: □ Yes □ No If yes, please list any and all diagnoses: _________________________________________________________When was your last physical exam: ________________Physician’s Name: ______________________________ Physician’s Phone Number: ______________________ Would you sign a release of information to coordinate care with them: □ Yes □ No Please list medications below. MedicationDose/FrequencyLength of Time Condition Being Treated__________________________ __________________ ___________ ______________________________________________________ __________________ ___________ ______________________________________________________ __________________ ___________ ______________________________________________________ __________________ ___________ ____________________________Please indicate any substances that are recreationally used—outside of a prescribed medication: Type WhenHow Often□ Alcohol□ Past □ Present□ Daily □ Weekly □ Monthly□ Prescription Drugs□ Past □ Present□ Daily □ Weekly □ Monthly□ Marijuana□ Past □ Present□ Daily □ Weekly □ Monthly□ Heroin□ Past □ Present□ Daily □ Weekly □ Monthly□ Cocaine□ Past □ Present□ Daily □ Weekly □ Monthly□ Hallucinogens□ Past □ Present□ Daily □ Weekly □ Monthly□ Other: _______________□ Past □ Present□ Daily □ Weekly □ MonthlyList your health conditions or illnesses: Note approximate date or age of the onset for each condition/illness. Health Condition or Illness Age or Date_______________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________Reason for CounselingHave you at any point past or present engaged in counseling: □ Yes □ No If yes: □ Psychiatrist □ Psychologist □ Social Worker □ Minister □ Counselor □ OtherWhat led you to end counseling or therapy: ______________________________________________________ In the best way you can, please explain your reason for choosing to begin counseling at this time.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Presenting Problems and ConcernsPlease identify your current symptoms.□ Addictions □ Anger/Temper Problems□ Anxiety □ Behavior Problems □ Crying□ Cutting/Hurting Yourself □ Depression □ Eating Problems □ Fears□ Financial Problems□ Hearing Voices/Seeing Things □ Homicidal Thoughts □ Inability to Focus/Concentrate □ Not Accomplishing Work/Tasks □ Obsessive-Compulsive Behaviors □ Pornography Problems□ Parenting Stress□ Panic Attacks □ Relationship Problems□ Sexual Problems□ Sexual Compulsions□ Sleep Problems □ Suicide Attempts□ Suicidal Thoughts If your symptom is not listed, please describe:____________________________________________________________________________________________________________________________________________________________________________________Briefly describe the role religion and spirituality play in your life:____________________________________________________________________________________________________________________________________________________________________________________ ................
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