Initial Intake Form
Please fill out this form as completely as possible because it will help us work with you. All information will be held in strict professional confidence unless otherwise directed by law.
First Name: Last Name: Birthdate:
Gender: MaleFemale Age: Home Phone: Cell Phone:
Occupation: Work Phone:
Employer: Employer Address:
SSN#: Driver's License#: Marital Status SingleMarriedDivorcedSeparatedEngaged
I cannot guarantee confidentiality when you and I are communicating via cell phone, cordless phone, fax, email or computer. These devices could compromise confidentiality.
By understanding the inherent risks of the aforementioned devices, you can make an informed choice about when/where/how to use these tools.
How do you prefer to be contacted? Home PhoneWork PhoneCell PhoneEmaiIn case of emergency, who should I contact and what is the number?
How did you learn about our counseling service? Google SearchFriend/IndividualEmail AdvertisementOther Person's Name (if applicable)
Person's Phone (if applicable)
May I send a thank you note to this referral source and mention your name? YesNo
Education: Last Grade completed (Prior to college): Other Education (List type and years)
GOALS OF COUNSELING/THE ISSUE AS YOU UNDERSTAND IT
Briefly complete the following:
Please tell me what you want to change:
How has this been a problem?
When did this problem first appear?
What have you done about it?
What help are you seeking?
What led you to seek help now?
INFORMATION ABOUT SPIRITUAL LIFE
Church Address (List city and state if address not known):
Church Attendance Frequency (times per month):
Do you pray to God? YesHow often?
Have you come to the place in your spiritual life where you know for certain if you died tonight you would go to heaven? YesNo
IF YOU WERE TO DIE TONIGHT AND STAND BEFORE GOD AND HE ASKED, “WHY SHOULD I LET YOU INTO HEAVEN?”
WHAT WOULD YOU SAY?
HAVE YOU RECEIVED JESUS CHRIST PERSONALLY AS YOUR SAVIOR? YesNoUncertain
IF YOU HAVE RECEIVED CHRIST AS SAVIOR, WHAT CHANGES TOOK PLACE IN YOUR LIFE WHEN YOU BECAME A BELIEVER?
IF YOU HAVE RECEIVED CHRIST AS SAVIOR, HAVE YOU TOLD HOUSEHOLD/FAMILY MEMBERS ABOUT RECEIVING JESUS AS SAVIOR?
IF YES, WHOM HAVE YOU TOLD?
DO YOU READ THE BIBLE?YesNo How often? NeverOccasionallyOftenDaily
IF YOU PRAY, WHAT DO YOU PRAY ABOUT?
INFORMATION ABOUT PRIOR COUNSELING
HAVE YOU HAD ANY COUNSELING BEFORE? YesNo
COUNSELOR NAME(S) DATES FromTo
MEDICATION PRESCRIBED YesNo OUTCOME
INFORMATION ABOUT PERSONAL HABITS AND HEALTH
APPROXIMATELY HOW MANY HOURS OF SLEEP DO YOU GET EACH NIGHT?
WHEN DO YOU NORMALLY:
go to bed? fall asleep?wake up? get out of bed?
IF THERE IS A LENGTH OF TIME BETWEEN YOUR WAKING UP AND GETTING OUT OF BED? YesNo
WHAT DO YOU DO DURING THAT TIME?
DESCRIBE ANY RECENT CHANGES IN YOUR SLEEP HABITS:
STATE OF HEALTH: Very GoodGoodAverageDecliningOther
DATE OF LAST MEDICAL EXAMINATION: RESULTS:
ARE YOU PRESENTLY TAKING MEDICATION?YesNo WHAT?
FOR WHAT REASON DO YOU TAKE THIS MEDICATION?
HAVE YOU USED DRUGS FOR OTHER THAN MEDICAL PURPOSES?YesNo WHEN?
DO YOU DRINK ALCOHOLIC BEVERAGES? YesNWHEN?
MARRIAGE AND FAMILY INFORMATION
NAME OF SPOUSE:
ADDRESS (if different):
SPOUSE PHONE #: OCCUPATION:
SPOUSE’S AGE: EDUCATION (in years): RELIGION:
IS SPOUSE WILLING TO COME WITH YOU TO COUNSELING? YesNoHave not asked yetNot certain
ARE YOU CURRENTLY SEPARATED? YesNo Since When?
HAVE YOU EVER BEEN SEPARATED IN THE CURRENT MARRIAGE? YesNo
No. of times? HAS EITHER OF YOU EVER FILED FOR DIVORCE? YesNo When? Who? MeSpouse
DATE OF MARRIAGE? YOUR AGES WHEN MARRIED: Husband? Wife?
HOW LONG DID YOU KNOW YOUR SPOUSE BEFORE MARRIAGE? (in months)
LENGTH OF STEADY DATING WITH SPOUSE (months): LENGTH OF ENGAGEMENT (months):
HAVE YOU BEEN MARRIED BEFORE? YesNo IF YES, HOW MANY TIMES? Husband Wife
IF YOU WERE MARRIED BEFORE, HOW DID THE MARRIAGE(S) END?
Age Gender MaleFemale Living? YesNo Education (In Yrs) Marital StatusMarriedSingleDivorcedSeparated From Previous Marriage YesNo
Age Gender MaleFemale Living? YesNo Education (In Yrs) Marital StatusMarriedSingleDivorcedSeparated From Previous Marriage YesN
IF YOU WERE REARED BY ANYONE OTHER THAN YOUR OWN PARENTS, BRIEFLY EXPLAIN:
NO. OF OLDER Brothers Sisters NO. OF YOUNGER Brothers Sisters