Intake Form
Please provide the following information. Information provided is protected as confidential information.
Client Full Name: ______
Address: ______
(Street) (City) (State) (Zip)
Client Birth Date ______/______/______Age: ______Gender: ______
Phone: ______E-mail: ______
Name of Parent/Guardian (if under 18 years): ______
Address: ______
(Street) (City) (State) (Zip)
Phone: ______E-mail: ______
Name of Other Parent/Guardian: ______
Address: ______
(Street) (City) (State) (Zip)
Phone: ______E-mail: ______
Client Marital Status: ______Parent/Guardian Marital Status: ______
Home Phone: ______May we leave a message? Yes No
Cell Phone: ______May we leave a message? Yes No
Work Phone: ______May we leave a message? Yes No
Email Address: ______May we email you? Yes No
*Please note: Email correspondence is not considered to be a confidential medium of communication.
Insurance Company: ______
Policy Number: ______
How did you hear about Solutions for Success Counseling Group?
______
Have you previously received any type of mental health services? Yes No
Explain ______
Do you have any current mental health diagnoses? Yes No
Explain______
Are you currently taking any prescribed psychiatric medicine? Yes No
Explain______
General and Mental Health Information
How would you rate your current physical health?
Poor Unsatisfactory Satisfactory Good Very good
Please list any specific health problems you are currently experiencing:
______
How would you rate your current sleeping habits?
Poor Unsatisfactory Satisfactory Good Very good
How many hours per week do you generally exercise? ______
Do you drink alcohol? Yes No How much per week? ______
Do you use any drugs? Yes No How much per week? ______
Have you ever engaged in self-harm? Yes No When? ______
Have you ever contemplated hurting someone?Yes No When? ______
Have you ever contemplated suicide?Yes No When? ______
Family Mental Health History
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).
Alcohol/Substance Abuse Yes No Who? ______
Anxiety Yes No Who? ______
Depression Yes No Who? ______
Domestic Violence Yes No Who? ______
Eating Disorders Yes No Who? ______
Obesity Yes No Who? ______
OCD Behavior Yes No Who? ______
Schizophrenia Yes No Who? ______
Suicide Attempts Yes No Who? ______
Additional Information
Are you currently employed? Yes No For how long? ______
Where? ______
Are you currently a student? Yes No Grade: ______
Where? ______
Do you consider yourself to be spiritual/religious? Yes No Explain: ______
What do you consider to be some of your strengths? ______
______
______
What do you consider to be some of your weaknesses? ______
______
______
What would you like to accomplish during your time in therapy? ______
______
______
Any additional information:______
______
Intake completed by: ______Date: ______
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