Charis Christian CounselingIntake Form

Privacy Statement: Any information provided by a consumer via our online forms will be held in the strictest confidence. No information will be shared with others. We will make every effort to respond to your submission within 2 business days.

Today’s date: / ______
Identification and Contact Information
Name: / Nickname or name you prefer to be called:
Birth date: / ______/ Age: / Gender: Male Female
Type of identification:
Passport # Official ID US Driver’s License… / State: / ID #:
Contact
Address:
City: / State: / Zip/Postal Code: / Country/Province:
Do not include any phone numbers you don’t want to be used to contact you.
Home: / Is it okay to leave a message on your home phone? Yes No
Cell: / Is it okay to leave a message on your cell phone? Yes No
Work: / Is it okay to leave a message on your work phone? Yes No
Email address:
Emergency Contact
Who should be contacted in case of emergency?
Relationship to client: / Home phone: / Work phone:
Psychiatrist: / Phone:
Counseling Issues
What concern has prompted you to contact me at this time?
How has this problem affected your life in the following areas?
Family
Work
Social
Recreationally
Health
Spiritually
How long have you had this problem?
Please list any important events in your life that may relate to this problem.
How serious is this problem?
mildly serious moderately serious very serious extremely serious crisis level
What have you tried to do to solve this problem?
What has been successful?
Have you had counseling in the past? / Yes No
If so, where? / When?
What was helpful about the counseling?
What was not helpful about the counseling?
Medical History
How would you rate your current health? / very poor poor average good excellent
Are you currently being treated by another therapist or psychiatrist? / Yes No
Are you currently experiencing any negative feelings or “symptoms” at this time (e.g., feeling anxious, depressed, sad, angry, frustrated, etc.)? / Yes No
If so, please specify.
How severe would you say your symptoms are? / mild moderate severe
Are you currently taking any psychotropic medication (e.g., anti-depressants or anti-anxiety medication)? / Yes No
If so, what kind of doctor prescribed it? / Physician Psychiatrist Other…
Have you taken psychotropic medications in the past? / Yes No
Please list all medication you are not taking, including the dosage. Include prescriptions, over-the-counter, herbal, homeopathic medications and nutritional supplements.
Have you ever been hospitalized for drug or alcohol abuse, a suicide attempt, “nerves” or other mental health concern? / Yes No
If yes, please give dates and circumstances.
List current health problems for which you are receiving treatment.
Drug and Alcohol Use
What is your current use of alcohol?
Have you had any problems with alcohol in the past? / Yes No
If yes, please explain:
What is your current use of other drugs?
Have you been arrested for alcohol/drug related offenses? / Yes No
Have you had treatment for problems with alcohol abuse/dependency? / Yes No
Do you have a history of drug use? / Yes No
Have you had treatment for drug abuse/dependency? / Yes No
Have you ever lost a job/relationship due to the use of alcohol/drugs? / Yes No
Symptoms
Current Past: Please check all that apply to you.
Thoughts of suicide
Plan for suicide
Suicide attempt
Hurting yourself deliberately
Thoughts of hurting someone else
Severity of Symptoms
Check all that apply to you.
Sleep too much / Loss of sexual desire / Noticing items in your home and not knowing where they came from or how they got there
Sleep too little / Outbursts of anger / Feelings of being controlled by forces outside yourself
Interrupted sleep / Change in appetite / Feeling compelled to repeat activities for no reason
Other sleep problems / Hearing voices when no person is present / Unable to relax
Memory / Unable to recall periods of childhood after age 5 / Blackouts
Concentration / Unable to recall some period of your day / Excessive sweating
Attention / Walking in your sleep / Death of family members or friends
Loss of interest in usual activities / Nightmares / Panic attacks
Feelings of sadness / Overwhelming fears / Mood swings
Loss of energy / Racing thoughts / Spending sprees
Feeling tired all the time / Thoughts that won’t go away that are constantly in your head / Changes in energy level
Periods of crying / Thoughts of harming someone else / Other:
Feeling of hopelessness / Thoughts that some person or people are trying to harm you
Work History
Usual occupation:
Are you currently employed: / Yes No / Length of time:
If you have change jobs during the last 5 years, give duration of employment and reason for leaving job.
Psychosocial and Environmental Problems
Please rate each of the following problem areas that have been present during the past year or those occurring prior to one year if they clearly contribute to the reasons seeking treatment.
No significant problem
Moderate
Serious / Problems with primary support group: Death of a family member, separation, divorce, removal from home, sexual or physical abuse, discord in the family with parents, siblings, or other like events.
No significant problem
Moderate
Serious / Problems related to the social environment: death or loss of a friend, living alone, discrimination, or adjustment to life-cycle transitions, such as leaving home or retirement.
No significant problem
Moderate
Serious / Educational problems: Unable to read, academic problems, discord with teachers or classmates.
No significant problem
Moderate
Serious / Occupational problems: Unemployment, threat of job loss, stressful work schedule, discord with boss or co-workers.
No significant problem
Moderate
Serious / Housing problems: Homeless, unsafe neighborhood, discord with neighbors or landlord.
No significant problem
Moderate
Serious / Economic problems: Not enough money to pay bills, food and rent.
No significant problem
Moderate
Serious / Problems with access to health care services: Inadequate health care, transportation to health care facilities unavailable, inadequate health insurance.
No significant problem
Moderate
Serious / Problems related to interaction with the legal system/crime: Arrest, incarceration, litigation, victim of a crime.
No significant problem
Moderate
Serious / Other psychosocial and environmental problems: Exposure to disasters, discord with non-family caregivers such as counselor, social worker or physician, unavailability of social service agencies.
Personal History
Marital Status
Single
Married—how long?
Previously married—how many times?
Living with someone—how long?
Separated—how long?
Widowed—how long?
Family History
Who raised you?
If there were changes, please list and indicate the age you were when these changes occurred:
Number of siblings: / Number of brothers: / Number of sisters
List you and your siblings from oldest to youngest:
Name / Age / Gender / Name / Age / Gender
1 / M F / 5 / M F
2 / M F / 6 / M F
3 / M F / 7 / M F
4 / M F / 8 / M F
Which members of your family are close to you?
Which family members are problems for you?
Please indicate other people in your life that provide support for you:
Please check any problems that family members have or have had and indicate relationship:
Relationship
Arrests/convictions
Alcoholism
Depression
Violence
Other mental/emotional problems (list below)
Your Childhood
Check any of the following that apply to your childhood/adolescence:
Happy childhood / Family problems
School problems / Alcohol use
Medical problems / Drug use
Unhappy childhood / Arrests/convictions
Check any of the following that apply to your being a victim, past or present:
Current sexual abuse / Current domestic violence
Past sexual abuse / Past domestic violence
Current physical abuse / Current emotional abuse
Past physical abuse / Past emotional abuse
Educational History
Years completed:
Problems:
Strengths:
Religious/Spiritual History
Are spiritual or religious resources important in your coping? / Yes No
Are you open to sharing this part of your life as appropriate in your treatment? / Yes No
Comments

Page 1 of 1