COUNSELING INTAKE FORM
Disclaimer: Thank you for your interest in being a client of [COUNSELOR’S NAME] .
Information collected about new clients is confidential and will be treated accordingly.
DETAILS
Name: _____________________ Gender: Male Female Other
Street Address: __________________________________________
City: _____________________ State: _____________________ Zip Code: ________
E-Mail: _____________________ Phone: _____________________
Date of Birth: ____/____/____
Ethnicity/Race: _____________________
Education: GED High School Bachelor’s Master’s Ph.D.
RELIGION
Do you currently practice a religion? Yes No
-If yes, what is your faith? _____________________
EMERGENCY CONTACT
Emergency Contact Name: _____________________
Relationship: _____________________
E-Mail: _____________________ Phone: _____________________
RELATIONSHIP STATUS
Marital Status: Single Married Divorced Widowed
Page 1 of 6
Length of Current Relationship: _____________________
Assessment of Current Relationship: Poor Fair Good Great
Number of Marriages: ____
EMPLOYMENT
Are you currently employed? Yes No
Employer’s Name: _____________________ Occupation: _____________________
Pay: $____________ per year (approx.)
Street Address: __________________________________________
City: _____________________ State: _____________________ Zip Code: ________
Phone: _____________________
MILITARY HISTORY
Military Experience? Yes No Combat Experience? Yes No
Branch: _____________________ Length of Service: _____________________
Type of Discharge: _____________________ Rank: _____________________
HOUSEHOLD AND FAMILY
List your current immediate family:
Name: _____________________ Relationship: _____________________ Age: ____
-Living with you? Yes No
Name: _____________________ Relationship: _____________________ Age: ____
-Living with you? Yes No
Name: _____________________ Relationship: _____________________ Age: ____
-Living with you? Yes No
Name: _____________________ Relationship: _____________________ Age: ____
-Living with you? Yes No
Name: _____________________ Relationship: _____________________ Age: ____
-Living with you? Yes No
Page 2 of 6
MEDICAL INFORMATION
Primary Care Physician: _____________________ Phone: _____________________
Street Address: __________________________________________
City: _____________________ State: _____________________ Zip Code: ________
List any current medical problems: _________________________________________
List any current medications: _________________________________________
List any current allergies: _________________________________________
Have you taken medication for a mental health concern? Yes No
Medication Name: _____________________ Dates: _____________________
-Was it helpful? Yes No
Medication Name: _____________________ Dates: _____________________
-Was it helpful? Yes No
Medication Name: _____________________ Dates: _____________________
-Was it helpful? Yes No
MEDICAL INSURANCE
Primary Insurance Company: _____________________
Policyholder’s Name: _____________________ Group #: _____________________
ID #: ______________ Type: HMO PPO Medicare Other: ______________
PREVIOUS COUNSELING
Have you previously seen a counselor? Yes No
-If yes, who and where: ________________________________________
Approximate dates of counseling: ________________________________________
Reason for counseling: ________________________________________
Do you have a previous mental health diagnosis? Yes No
-If yes, describe: ________________________________________
Page 3 of 6
What did you find most helpful in therapy? ___________________________________
What did you find least helpful in therapy? ___________________________________
Have you used psychiatric services before? Yes No
ALCOHOL & DRUG USE
Do you currently consume alcohol? Yes No
How often? Daily Weekly Occasionally Rarely
How many drinks? ____ drink(s)
Do you currently smoke? Yes No
What do you smoke? Tobacco Marijuana Other: ___________________
Do you currently use any other drugs? Yes No
What other drugs do you take? _______________________________________
How often? Daily Weekly Occasionally Rarely
Have you ever received treatment for alcohol or drug use? Yes No
Where did you go? _________________________________________
Inpatient Outpatient
Have you ever felt the need to cut down on your drinking/drug use? Yes No
Have you ever had other people criticize your drinking or drug use? Yes No
Have you ever felt bad or guilty about drinking or drug use? Yes No
Have you ever had a drink or used drugs first thing in the morning? Yes No
CURRENT ISSUES
What are the main issues for which you are seeking counseling?
______________________________________________________________________
When did these issues first start?
______________________________________________________________________
What results would you like to get from counseling?
______________________________________________________________________
What is the most concerning issue for you right now?
______________________________________________________________________
Page 4 of 6
FAMILY CONCERNS
Please check ANY of the following family concerns you are experiencing:
- Abuse / neglect - Inadequate housing / feeling unsafe
- Arguing - Infidelity
- Alcohol use - Feeling distant
- Birth of a family member - Job change
- Death of a family member - Job dissatisfaction
- Divorce / separation - Loss of fun
- Drug use - Lack of honesty
- Education problems - Lack of intimacy
- Financial problems - Marriage issues
- Inadequate health insurance - Physical fighting
List any other family concerns: _____________________________________________
PERSONAL CONCERNS
Please select the severity of EACH of the following concerns:
Alcohol use - None Mild Moderate Severe
Anger issues - None Mild Moderate Severe
Anorexia - None Mild Moderate Severe
Anti-social behavior - None Mild Moderate Severe
Anxiety / paranoia - None Mild Moderate Severe
Appetite changes - None Mild Moderate Severe
Bi-polar behavior - None Mild Moderate Severe
Binging / purging - None Mild Moderate Severe
Crying - None Mild Moderate Severe
Decreased sex drive - None Mild Moderate Severe
Drug use - None Mild Moderate Severe
Excessive worrying - None Mild Moderate Severe
Fear of death - None Mild Moderate Severe
Headaches / migraines - None Mild Moderate Severe
Hopelessness - None Mild Moderate Severe
Hyperactivity - None Mild Moderate Severe
Impulsivity - None Mild Moderate Severe
Inability to focus - None Mild Moderate Severe
Indecisiveness - None Mild Moderate Severe
Low energy - None Mild Moderate Severe
Low self-worth - None Mild Moderate Severe
Nausea / indigestion - None Mild Moderate Severe
Nightmares - None Mild Moderate Severe
Page 5 of 6
Panic attacks - None Mild Moderate Severe
Poor concentration - None Mild Moderate Severe
Problems at home - None Mild Moderate Severe
Racing thoughts - None Mild Moderate Severe
Restlessness - None Mild Moderate Severe
Sadness - None Mild Moderate Severe
Self-mutilation - None Mild Moderate Severe
Sleep deprivation - None Mild Moderate Severe
Spiritual concerns - None Mild Moderate Severe
Suicidal thoughts - None Mild Moderate Severe
Trauma flashbacks - None Mild Moderate Severe
Unresolved guilt - None Mild Moderate Severe
Weight (over or under) - None Mild Moderate Severe
Work issues - None Mild Moderate Severe
Workaholic (working too much) - None Mild Moderate Severe
List any other concerns: __________________________________________________
SIGNATURE
Signature: ______________________ Date: ______________________
Print Name: ______________________
Page 6 of 6
