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The Healing Place

Therapy & Counseling Services for Children, Adolescents, & Adults

Adult Intake Form

I.GENERAL INFORMATION Today’s Date: ______

Client Name: ______Gender: ☐M ☐F Date of Birth: ______

Ethnic/cultural background ______PrimaryLanguage: ______

Address: ______

Street City StateZip

Contact Phone: ______Contact Email: ______

Currently Employed? ☐Yes ☐No Current/Last Occupation: ______

Current Martial Status: ☐Married(for______) ☐Single ☐Separated ☐Divorced ☐Widowed

Married before?☐Yes ☐No # biological/adopted children ____ # step-children ____

II.REFERRAL INFORMATION

What is the main reason you are requesting therapy services:

III.FAMILY RELATIONSHIPS (Please identify all the people living in your home below)

Name /

Sex

/ Age / Relationship to You
(i.e. person is my son, partner, etc.) /

Please list any concerns or conflicts you have with this person

How would you describe your relationship with your children?
How do you and the child(ren)’s other parent(s) get along?
What would you say are your strengths as a parent (what you do well)?
Weaknesses or areas you would like to improve?

Family of Origin

Your Mother’s Name: / Your Father’s Name:
Her Date of Birth /Age: / His Date of Birth /Age:
Where does she live: / Where does he live:
Describe your relationship with her: / Describe your relationship with him:

Significant Others-Please identify major people NOT in your home that are significant in your life:

Name /

Sex

/ Age / Relationship to You
(i.e. person is my son, partner, etc.) /

Please list any concerns or conflicts you have with this person

IV.MEDICAL HISTORY

Did you have any significant childhood illnesses?

If yes, explain: ______

Did you ever experience:

high fever severe fall head trauma loss of consciousness surgery If yes, # ____

Notes:______

Do you have any physical disabilities? Y N If yes, explain ______

Are you currently having any medical problems? Y N

If yes, explain: ______

Are you currently taking any medication(s)? Y N

If yes, names, dosage, purpose: ______

______

V.EDUCATIONAL HISTORY

Highest grade completed _____ Did you like school? Y N

Why/Why not?______

What subjects were you good at? ______

Which subjects were difficult?______

Did you have any learning difficulties? Y N

If yes, explain ______

Did you fail any grades? Y N If yes, which ones? ______

What grade(s) did you get most often? A B C D F

Did you ever skip school? Y N If yes, explain______

Were you ever suspended or expelled from school? Y N

Were you ever involved in extracurricular activities? Y N If yes, what?______

VI.SOCIAL HISTORY

How many friends did you have in childhood? Many Few None

Current # of friends? Many Few None

Did you ever run away from home? Y N

If yes, when and why? ______

What is your religious affiliation? ______

Is spirituality important to you? Y N

Do you attend religious services? regularlyonce in a while never

VII.SEXUAL HISTORY

Do you consider yourself:HeterosexualHomosexualBisexual

How did you learn about sex? FriendsSchoolParents Other ______

Compared to kids your age, did you enter puberty:EarlyOn timeLate

How old were you when you first became sexually active? ______

Are you in a sexual relationship(s) now? Y N If yes, with whom? ______

Have you had any sexual problems in the past? Y N Are you having any now? Y N

VIII.PSYCHOLOGICAL HISTORY

Have you ever experienced what you would consider “abuse”? Y N

sexual physical emotional neglect

If yes, when and by whom? (Please share as much as your are comfortable disclosing at this time)
Did any of the abuse involve animals? / Yes / No
Have you ever seen a psychiatrist before / Yes / No
If yes, please describe who, when, for what, and whether you are still seeing this person for services:
Have you ever seen a therapist/counselor before? / Yes / No
If yes, please describe who, when, for what, and whether you are still seeing this person for services:
Have you ever hurt yourself or attempted suicide? / Yes / No
If yes, please share the number of times, the circumstances of the attempt, and what medical/psychological treatment was received afterwards (if any):
Have you ever purposely hurt your body in any way? / Yes / No
If yes, please share the number of times, the circumstances of the self-harm, and what medical/psychological treatment was received afterwards (if any)
Are you currently having any thoughts of hurting yourself? / Yes / No
If yes, please describe:
Are you having any problems or concerns with sleep? / Yes / No
If yes, please describe:
Are you having any problems or concerns with eating? / Yes / No
If yes, please describe:
Have you ever intentionally hurt or abused animals? / Yes / No
If yes, please describe:
Have you ever witnessed animals being abused by anyone? / Yes / No
If yes, please describe:
Has anyone in your family ever been diagnosed with an emotional or psychological disorder? If yes, please explain: / Yes / No
On the scale below, please circle/bold how you have been feeling most days for the past two weeks:
Horrible OK Good Fantastic

IX.SUBSTANCE ABUSE HISTORY

Have you EVER used any of the following legal or illegal drugs?
Substance / Yes / No / How old were you when you first used the substance? / Are you currently using this substance? / How often do you use this substance? / On average, how much do you use each time?
Cigarettes
Alcohol
Marijuana
Cocaine
Meth.
Other
Have any of the above drugs ever been a problem for you? / Yes / No
If yes, please describe:
Have you ever tried to quit using any of the above? / Yes / No
If yes, please describe:
Have you ever participated in a drug or alcohol rehabilitation program? / Yes / No
If yes, please describe:
Have you ever participated in a drug or alcohol rehabilitation program? / Yes / No
If yes, please describe:
Does anyone in your family have a drug or alcohol problem? / Yes / No
If yes, please describe:

X.LEGAL HISTORY

As an adolescent, did you ever have any trouble with the law? / Yes / No
If yes, please describe:
Have you ever been arrested? / Yes / No
If yes, please describe:
Have you ever been to jail or prison? / Yes / No
If yes, please describe:
Are you currently on any kind of probation or parole? / Yes / No
If yes, please describe:

XI.MAJOR LIFE EVENTS

Have you experienced any of the following life events in the past few years?

Event

/

Yes/No

/

If yes, please explain when & how you feel about the event:

Marriage
Death of a Loved One
Divorce/Separation
Car Accident
Move (#___)
Domestic Violence
Birth of a New Baby
Miscarriage/Abortion
Unemployment
Legal Problems
Other?
Is there anything else that was not asked that is important for me to know about you or that you would like me to be aware?

XII.THANK YOU!

Thank you for taking the time to complete this form. You may email the form back to me at or bring a completed copy with you to our next appointment.

This information is important for me to ensure that I provide the best services to you. I assure you that all your information will remain confidential as part of your record. As an adult only you or a legal guardian have access to the record upon request. Please note, that this record along with other documentation about services rendered may be subpoenaed by a court of law. If the record is subpoenaed you will be notified and informed of your rights. If you have any questions or concerns you may contact

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