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.

PERSONAL INFORMATION

First Name: Last Name: Birthdate:

Gender: Age:   Home Phone:   Cell Phone:

Address: E-Mail:

Occupation: Work Phone:

Employer: Employer Address:

SSN#: Driver's License#: Marital Status

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?  In case of emergency, who should I contact and what is the number?


REFERRAL INFORMATION

How did you learn about our counseling service? 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?


EDUCATION

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 Name:

Church Address (List city and state if address not known):

Pastor's Name:

Church Attendance Frequency (times per month):

Do you pray to God? How 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?

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?

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? How often?

IF YOU PRAY, WHAT DO YOU PRAY ABOUT?


INFORMATION ABOUT PRIOR COUNSELING

HAVE YOU HAD ANY COUNSELING BEFORE? 

COUNSELOR NAME(S) DATES  FromTo

MEDICATION PRESCRIBED       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? 
WHAT DO YOU DO DURING THAT TIME?

DESCRIBE ANY RECENT CHANGES IN YOUR SLEEP HABITS:

STATE OF HEALTH:

DATE OF LAST MEDICAL EXAMINATION: RESULTS:

ARE YOU PRESENTLY TAKING MEDICATION? WHAT?

DOSAGE?

FOR WHAT REASON DO YOU TAKE THIS MEDICATION?

HAVE YOU USED DRUGS FOR OTHER THAN MEDICAL PURPOSES? WHEN?

WHAT? AMOUNTS/DOSAGES?

DO YOU DRINK ALCOHOLIC BEVERAGES? WHEN?

HOW MUCH?

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?  

ARE YOU CURRENTLY SEPARATED?    Since When?

HAVE YOU EVER BEEN SEPARATED IN THE CURRENT MARRIAGE?

 No. of times? HAS EITHER OF YOU EVER FILED FOR DIVORCE?    When?  Who?

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?   IF YES, HOW MANY TIMES?  Husband Wife 

IF YOU WERE MARRIED BEFORE, HOW DID THE MARRIAGE(S) END?

CHILDREN’S                                                             
NAMES                                                     

Age Gender Living? Education (In Yrs) Marital Status From Previous Marriage

Age Gender Living? Education (In Yrs) Marital Status From Previous Marriage

Age Gender Living? Education (In Yrs) Marital Status From Previous Marriage

Age Gender Living? Education (In Yrs) Marital Status From Previous Marriage

Age Gender Living? Education (In Yrs) Marital Status From Previous Marriage

IF YOU WERE REARED BY ANYONE OTHER THAN YOUR OWN PARENTS, BRIEFLY EXPLAIN:

NO. OF OLDER Brothers Sisters NO. OF YOUNGER Brothers Sisters