Counselling Intake Form

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Counselling Intake Form

Please complete all information relevant to you and bring this form to the first visit. You may need to ask family members about the family history. NB: You do not need to answer any questions you find uncomfortable.

Name______Date______

Date of Birth ______Doctor ______

Previous Counsellor ______

What are the main problem(s) for which you are seeking help?

1.______

2.______

What are your current goals for treatment?

______

______

What methods have you tried before?______

______

Why haven’t they worked for you? ______

______

What did you not enjoy about the last counsellors methods? ______

______

Current Symptoms Checklist:

Check once for any symptoms present, twice for major symptoms

( ) Depressed mood ( ) Racing thoughts ( ) Excessive worry/ Ruminating on negative thoughts

( ) Unable to enjoy activities ( ) Impulsivity ( ) Panic attacks

( ) Sleep pattern disturbance ( ) Increase risky behavior ( ) Avoidance of activities

( ) Loss of interest in life or normal activities ( ) Hallucinations

( ) Concentration/forgetfulness ( ) Decrease need for sleep ( ) Suspiciousness/ Paranoia

( ) Change in appetite ( ) Excessive energy ( ) Excessive Exercise

( ) Excessive guilt ( ) Increased irritability ( ) ______

( ) Fatigue ( ) Crying spells ( ) Perfectionism

( ) Decreased libido ( ) Excessive libido ( ) ______

Suicide Risk Assessment

Have you ever had feelings or thoughts that you didn't want to live? ( ) Yes ( ) No.

If YES, please answer the following. If NO, please skip to the next section.

Do you currently feel that you don't want to live? ( ) Yes ( ) No

How often do you have these thoughts?______

Do you feel hopeless and/or worthless? ______

When was the last time you had thoughts of dying? ______

Has anything happened recently to make you feel this way? ______

On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? ______

Would anything make it better? ______

Have you ever thought about how you would kill yourself? ______

Is the method you would use readily available? ______

Have you planned a time for this? ______

Is there anything that would stop you from killing yourself? ______

Have you ever tried to kill or harm yourself before? ______

Do you have means to follow through with your plan? If yes, please explain______

______

Medical History:

Allergies______Current Approx Weight ______Height ______

List ALL current prescription medications and how often you take them: (if none, write none)

Medication Name Daily Dosage Length of use

______

______

______

______

______

Current over-the-counter medications, herbal or protein supplements: ______

______

Current medical problems: ______

______

Past medical problems, non-psychiatric hospitalisation, or surgeries: ______

______

______

Do you have concerns about your health that you would like to discuss with the counsellor? ( ) Yes ( ) No

Approximate date of last physical exam with physician: ______

Personal and Family Medical History:

Is there any personal or family medical history that might be relevant to your counselling? Please explain:

______

______

When your mother was pregnant with you, were there any complications during the pregnancy or birth?

______

Past Psychiatric History or Hospitalisation:

Please describe when, by whom, and nature of treatment.

Reason Dates Treated By Whom

______

______

______

Past Psychiatric Medications: If you have ever taken any of the following medications, please indicate the

dates, dosage, and how helpful they were (if you can't remember all the details, just write in what you do

remember): These include Antidepressants, Mood stabilisers, Anti-psychotics

Dates Dosage Response/ Side-Effects

______

______

Your Exercise Level:

Do you exercise regularly? ( ) Yes ( ) No

How many days a week do you get exercise? ______

How much time each day do you exercise? ______

What kind of exercise do you do? ______

Family Psychiatric History:

Has anyone in your family been treated (or should have been treated for) the following:

Bipolar disorder ( ) Yes ( ) No Schizophrenia ( ) Yes ( ) No

Depression ( ) Yes ( ) No Post-traumatic stress ( ) Yes ( ) No

Anxiety ( ) Yes ( ) No Alcohol abuse ( ) Yes ( ) No

Anger ( ) Yes ( ) No Other substance abuse ( ) Yes ( ) No

Suicide ( ) Yes ( ) No Violence ( ) Yes ( ) No

If yes, who had each problem? ______

______

Has any family member been treated with a psychiatric medication? Please specify:

______

______

Substance Use:

Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No

If yes, for which substances? ______

How many days per week do you drink any alcohol? ______

In the past 3 months, what is the largest amount of alcohol you have consumed in one day? ______

Have you used any street drugs or abused prescription medicine in the past 3 months? ( ) Yes ( ) No

If yes, which ones? ______

Do you think you may have a problem with alcohol or drug use? ( ) Yes ( ) No

How many caffeinated beverages do you drink a day? Coffee ______Sodas ______Tea ______

Tobacco History: How you ever smoked cigarettes? ( ) Yes ( ) No Currently? ( ) Yes ( ) No

How many packs per day on average? ______How many years? ______

Family Background and Childhood History:

Were you adopted? ( ) Yes ( ) No

Where did you grow up? ______

List your siblings and their ages: ______

______

What was your father's occupation? ______

What was your mother's occupation? ______

Did your parents' divorce? ( ) Yes ( ) No If so, how old were you when they divorced? ______

If your parents divorced, who did you live with?______

Describe your father and your relationship with him: ______

______

Describe your mother and your relationship with her: ______

______

How old were you when you left home? ______

Has anyone in your immediate family died? Who and when? ______

______

Trauma History:

Do you have a history of being abused emotionally, sexually, physically or by neglect? ( ) Yes ( ) No.

Please describe when, where and by whom: ______

______

Occupational History: Are you currently: ( ) Working ( ) Student ( ) Unemployed ( ) Disabled ( ) Retired

How long in present position? ______

What is/was your occupation? ______

Where do you work? ______

Relationship History and Current Family:

Are you currently: ( ) Married ( ) Partnered ( ) Divorced ( ) Single ( ) Widowed How long? ______

If not married, are you currently in a relationship? ( ) Yes ( ) No If yes, how long? ______

Are you sexually active? ( ) Yes ( ) No

How would you identify your sexual orientation?

( ) straight/ heterosexual ( ) lesbian/ gay/homosexual ( ) bisexual ( ) transsexual ( ) other

What is your spouse or significant other's occupation?

______

Describe your relationship with your spouse or significant other:

______

Have you had any prior marriages? ( ) Yes ( ) No. If so, how many? ______

How many years married? ______

Do you have children? ( ) Yes ( ) No If yes, list ages and gender: ______

______

Describe your relationship with your children: ______

List everyone who currently lives with you: ______

______

Legal History: Have you ever been arrested? ______

Do you have any pending legal problems? ______

Do you belong to a particular religion or spiritual group? ( ) Yes ( ) No

Is there anything else that you would like us to know?

______

______

______

Please read:

Confidentiality is maintained for clients as far as possible, and records are protected under numbers rather than names to avoid admin staff from accidentally reading private material. However, when a person or persons are believed to be at risk of serious harm, confidentiality must be waived under a duty of care (Legal Mandatory Reporting). This means that the appropriate authorities, and/ or family members will be notified by the counsellor, in accordance with Qld law.
A Confidentiality Breach is acceptable under the following circumstances:

• A client is at risk of serious self-harm, or is considering suicide
• The probable or past harming of another person
• A client has divulged details of a recent criminal offence, or planning one
• Abuse of children or elders is a mandatory reporting offence
• Counsellor is subpoenaed to disclose minimal notes to solicitors in relation to a client's court case
• For the psychiatric diagnosis of an illness with client consent, or via involuntary induction into hospital

If confidentiality cannot be maintained, the counsellor will take all possible steps to first ask for client consent for disclosure. Copy of the ACA Code of Ethics:

I have read the confidentiality clause, and have understood client rights as listed on the ACA website:

Signed______Date ______

Mobile ______Home phone #______

Address: ______

______

Guardian Signature (if under age 18) ______Date ______

Emergency Contact ______Telephone #______

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