Creative Life Counseling Services ph. 773.576.7032
Laura Foster, MA, ATR-BC, LCPC fax. 773-304-3566
1925 N. Milwaukee Ave.
Chicago, IL 60647
Adult (18+) Intake Form
Client Information Today’s date:______
Name:______
Home street address: ______Apt.:______
City: ______State: ______Zip: ______
DOB: ______Age: ______
Cell phone: ______Home phone: ______
Email: ______
Calls , texts, and emails will be discreet, but please indicate any restrictions:
B. Insurance/Payment information
Will you be using insurance to pay for sessions? Y N
Member’s name:______
Member’s date of birth:______
Insurance company:______
Member ID:______Group #:______
Dependents: ______
B. Referral:
How did you hear about us? ______
May I have your permission to thank this person for the referral? Yes No
C. Emergency contact:______
Phone:______Relationship:______
An emergency is considered to be any incident in which you are unable to consent to medical treatment.
Do I have your permission to contact this person in case of emergency? Y N
D. Have you seen a therapist before? Y N
If yes, when? ______
If yes, for what reason(s)? ______
E. Please list any medication, vitamins, or supplements and dosages you are currently taking:
F. Please list any hospitalizations (psychological or medical):
G. Please describe any family history of mental illness or substance abuse:
H. What is your relationship status?
I. Please summarize the reason you came to see me today:
Please check any current or past issues that apply to you.
Creative Life Counseling Services ph. 773.576.7032
Laura Foster, MA, ATR-BC, LCPC fax. 773-304-3566
1925 N. Milwaukee Ave.
Chicago, IL 60647
___Eating Disorders
___ Body Image
___ Academic Issues
___ Childhood Abuse (Physical, Sexual, Emotional)
___ Stress
___ Anxiety
___ Phobias (type: ______)
___ Alcohol/Other Drug Use
___ Sexual Assault/Rape
___ Grief and Loss
___ Divorce/Separation
___ Fertility Issues
___ Postpartum Depression
___ Spiritual Concerns
___ Depression
___ Impulsivity
___ Sexual Identity
___ Relationship Concerns
___ Family Distress
___ Financial Stress
___ Work Related Issues
Creative Life Counseling Services ph. 773.576.7032
Laura Foster, MA, ATR-BC, LCPC fax. 773-304-3566
1925 N. Milwaukee Ave.
Chicago, IL 60647
Other:______
Please feel free to elaborate on any issues:
If you are currently experiencing any of the following symptoms, please rate them using the number key below.
Never 0Seldom 1Often 2Always 3
Creative Life Counseling Services ph. 773.576.7032
Laura Foster, MA, ATR-BC, LCPC fax. 773-304-3566
1925 N. Milwaukee Ave.
Chicago, IL 60647
___ Difficulty concentrating
___ Memory loss or blackout
___ Crying
___ Difficulty sleeping
___ Missing work/class
___ Stealing
___ Feeling helpless
___ Anger
___ Feeling uptight/tense
___ Eating binges
___ Restrictive eating
___ Skin or hair picking
___ Worrying
___ Drinking heavily
___ Other drug use
___ Feeling hopeless
___ Feeling afraid
___ Feelings of guilt
___ Lying to others
___ Withdrawing socially
___ Feeling out of control
___ Sexual preoccupation/obsessions
___ Feelings of self-doubt
___ Physical symptoms (i.e. headaches, digestive)
List: ______
___ Self- Injury
___ Loneliness
___ Nervousness around others
____ Suicidal thoughts
____ Homicidal thoughts
Creative Life Counseling Services ph. 773.576.7032
Laura Foster, MA, ATR-BC, LCPC fax. 773-304-3566
1925 N. Milwaukee Ave.
Chicago, IL 60647
Other: