Initial Intake History for Adults
Identifying Data:Date(s) of Evaluation: ______
Name:______
Date of Birth: ______Age: _____Sex: _____
Spiritual/Religious Beliefs: ______
Marital Status:______
Please circle if you are: Gay Lesbian Trans Bisexual Other
If so, please indicate what pronoun you go by: ______
History:
If married/dating/living together, describe the relationship (include names, occupation, and age of significant other, as well as history of the relationship):______
______
______
Previous marriages for either? (If so, please provide details)______
Do you have any children? (If so, please give names, sex, age, grade, and indicate with whom they live) ______
______
Description of Presenting Problem/Issue:
State in your own words the nature of your problems (i.e., What brings you in today? Why now?):
______
______
When did the problem begin?
______
What else was going on at the time? ______
______What solutions to your problems have been most helpful?
______
Treatment Expectations:
What were you hoping to accomplish during counselling? What do you think counselling is all about?______
______
How long do you think it will it take for you to get better? ______
______How will you and I know when we are finished? ______
______
Treatment History:
Have you been in therapy before or received any prior professional assistance for your problems? If so, list name (s), professional title(s), and dates of treatments and results:
______
Please list all prescription medications you are currently taking (including medications “as needed”, birth control, etc.). Include the dosage taken per day and the reason for taking the medication.
MedicationDosageReason
______
Do you have a family physician?_____ Yes_____ No
If yes, please give his/her name(s) and telephone number(s)
______
Have you spoken to your family doctor about the nature of your difficulties?_____ Yes_____ No
Are there any other significant health problems/accidents that have not been discussed so far?
_____ Yes_____ No
If yes, please describe? ______
______
Have you ever been hospitalized for psychological problems?_____ Yes_____ No
If yes, when and where? ______
Have you ever attempted suicide?_____ Yes_____ No
Do you smoke cigarettes?_____ Yes_____ NoNumber per day: ______
What are your current drinking habits? ______
When in your life were you drinking the most? ______
What was your drinking behaviour during that time? ______
Do you use street drugs, illegal, or recreational drugs? ______
If so, please list: ______
Have you ever been hooked on a prescribed medication or taken a lot more of it than you were supposed to?_____ If so, please list: ______
Family History:
Father’s Name: ______
Living ______Deceased ______
If living, present age? ______
If deceased, age at time of death? ______
How old were you at the time? ______
Cause of death: ______
Occupation: ______
Mother’s Name: ______
Living ______
Deceased ______
If living, present age? ______
If deceased, age at time of death? ______
How old were you at the time? ______
Cause of death: ______
Occupation: ______
Siblings:
Number of brothers ______Age(s) of brother(s) ______
Number of sisters ______Age(s) of sister(s) ______
Your place in family (e.g., 3rd of 4 children) ______
How did you get along with your siblings? ______
______
Has any relative attempted or committed suicide? ______
Does any member or your family suffer from alcoholism, depression, or anything that can be considered a mental disorder? ______
Were you raised by your parents?_____ Yes_____ No
If not, who raised you and between what years? ______
______
Give a description of your father’s (or father’s substitute) personality and his attitude towards you (past and present): ______
______
Give a description of your mother’s (or mother’s substitute) personality and her attitude towards you (past and present): ______
______
In what ways were you disciplined (punished) by your parents as a child? ______
______
Give an impression of your home atmosphere in the home in which you grew up (mention the state of compatibility between parents and children): ______
______
Did you experience any significant disruptions as a child? (e.g., separation from one or both parents for an extended time, significant geographical move): ______
______
If you have a step-parent, give you age when parent remarried ______
Has anyone (parents, relatives, friends) ever interfered in your life (e.g., marriage or occupation)? ______
Marriage/Common Law Relationships
What is your spouse’s /partner’s age? ______
Please describe your partner’s/spouse’s current or most recent (occupation): ______
______
What words best describe your spouse’s/partner’s personality? ______
______
In what areas are you compatible (e.g., shared interests)? ______
In what areas are you incompatible (e.g., sources of conflict)? ______
______
If Single:Is there any common pattern that seems to take place in many of your romantic involvements/relationships?
______Are you involved in a relationship now? If so, please describe your relationship: ______
______
Sexual Relationships:
Was sex discussed in your home? _____ Yes_____ No
Describe your parent’s attitude towards sex: ______
______Are there any relevant details regarding your first or subsequent sexual experiences? ______
______
Is your present sex life satisfactory? ______If not, please explain: ______
______Friendships:
How do you get along with peers? ______Who is your best friend? Why?______
______Were you ever bullied or severely teased? Describe: ______
______
Describe any relationship that gives you:
(a) Joy______
(b) Grief______
When was the last time you laughed?______Generally, do you express your feelings, opinions, and wishes to others in an open, appropriate manner? Describe those with whom (or those situations in which) you have trouble asserting yourself: ______
______Do you have at least one friend with whom you feel comfortable sharing your most private thoughts and feelings? _____ Yes _____ No (If yes, indicate number): ______
Are you currently troubled by any past rejections of loss of a love relationship? ______
Work History:
What type of work are you doing now? ______
Have you had any difficulty keeping long-term jobs? (If yes, please explain) ______
______Does your current family income feel adequate for your needs? (If no, explain): ______
Does your present work satisfy you? ______If not, please explain: ______
______
How do you get along with your Co-workers? Peers? Subordinates? Boss? ______
______What would you like to change about work? ______
______
Hobbies and Activities:
How do you spend your free time? ______
Do you keep yourself compulsively busy doing an endless list of chores? ______
Do you practice relaxation or meditation regularly? ______
Do you have trouble relaxing and enjoying weekends and vacations? (If yes, please explain)
______
Do you have any recurring dreams ______yes ______no
If yes, please describe them:______
______
Completed By:______ / Date:
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