Artists Counseling Services

Lola Broomberg LPC

Artists Counseling Services

541 Willamette, Ste 207A, Eugene OR 97401

541-686-8119

www.lolabroomberg.com

Intake Evaluation:

Please complete the following information:

Client’s Name: Today’s date:

(Partner’s name, if being seen as a couple):

Address:

Telephone:

(home) (work) (cell)

May I leave messages for you at home:

May I leave messages for you at work:

Birthdate:

Health Insurance Information:

Name of Insurance Company:

Name of Subscriber:

Network:

ID Number:

Group Number:

PCN#

Customer Service number:

Co-pay per session:

Send claims to:

Counseling Agreement

As a client with Lola Broomberg LPC, I understand that the content of each session is confidential and will not be released to any person or agency without my written authorization.

I understand that for the purpose of my safety and protection, imminent harm to myself or others is excluded from this agreement.

I understand that the feel for counseling services is payable at the time of service.

Individual /Couples $150 (or $120 if paid at time of services)

Client Signature: ______Date: ______

Background Information:

Occupation: Employer

Emergency Contact

Phone:

Referred by:

2. PRESENTING CONCERNS

Describe what brings you to counseling?

Discuss possible outcomes you hope to achieve with counseling:

Check any of the symptoms that you are having:

Depression Feeling hopeless

Extreme sadness Feeling tearful

Trouble concentrating Change in sleeping habits

Memory problems Lack of energy

Change in eating habits Weight changes

Feeling of extreme happiness Change in sexual interest or function

Trouble performing your job Problems with friends/family

Lack of enjoyment of usual activities Feeling stressed

Self-esteem problem Easily irritated

Perfectionism Feeling guilty

Obsessions or compulsions Feeling nervous

Feeling fearful Sudden feelings of panic

Physical complaints of pain Muscle tension

Problems with anger Acting violently

Thoughts about hurting yourself/others Thoughts about killing yourself/others

Other:

Have you done counseling before?

Yes No

If you have had prior counseling experience, please describe it.

Start with the most recent time first.

A. When did you have counseling? Date(s):

Who did you see?

Explain what happened:

B. When did you have counseling?: Date(s):

Who did you see?

Explain what happened:

FAMILY INFORMATION:

Marital Status: Spouse/Partner’s name:

Children:

Parents:

Siblings:

Others living in the home:

Spiritual Practice/ Religious Affiliation

How would you describe your childhood?

Development

Are there special, unusual, or traumatic circumstances that affected your development?

Yes

No

If Yes, please describe:

Family History of Physical, Emotional, Sexual or Substance Abuse Issues?

MEDICAL INFORMATION

Please list all current medications:

Current Medical Issues

Have you seen a doctor within the past year

Yes No

Why have you seen a doctor?

Who is your doctor:

Do you have allergies to anything?

Please describe allergy problems that you may have:

SUBSTANCE USE HISTORY

Do you use/ have you used tobacco (any form) Current past No

Do you use/have you used alcohol? Current past No

Caffeine in any form (soda included) Current past No

Recreational drugs Current past No

If use is current: please specify substance choice and frequency of useage

Have you experienced negative effects from alcohol or drug use?

Include physiological, work or social problems