Adult intake form

Today’s date: ___________________________ Your name: ____________________________________________ Date of birth: __________________ Age: ____ Nicknames or aliases: ____________________________________ Social Security #: _______________________ Home street address: ________________________________________________________ Apt.: ______________ City: ___________________________________________________________ State: _____ Zip: ______________ Home/evening phone: ______________________________ e-mail: ______________________________________ Calls or e-mail will be discreet, but please indicate any restrictions: _______________________________________ B. Referral: Who gave you my name to call? Name: ________________________________________________________ Phone: _________________________ Address: ______________________________________________________________________________________ May I have your permission to thank this person for the referral? ❑ Yes ❑ No How did this person explain how I might be of help to you? _____________________________________________ _____________________________________________________________________________________________ C. Religious and racial/ethnic identification Current religious denomination/affiliation ❑ Protestant ❑ Catholic ❑ Jewish Other (specify): _______________________________________________ Involvement: ❑ None ❑ Some/irregular ❑ Active How important are spiritual concerns in your life? _____________________________________________________ Which (if any) church, synagogue, temple, or meeting are you involved with? ________________________________ Ethnicity/national origin: ______________________________ Race: _________________________ or other similar way you identify yourself and consider important: __________________________________________________________ D. Your medical care: From whom or where do you get your medical care? Clinic/doctor’s name: ____________________________________________ Phone: _______________________ Address: ________________________________________________________________________________________ If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be fully informed and we can coordinate your treatment? Your Name________________________________________________ Today’s Date ___________________ ____________________________________________________________________________________________________ Employer: ________________________________________ Address: _______________________________________ Work phone: _____________________________ or other means of communication ____________________________ Calls will be discreet, but please indicate any restrictions: _________________________________________________ If some kind of emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we call? Name: __________________________________ Phone: ____________________ Relationship: ________________ Address: _______________________________________________________________________________________ Significant other/nearest friend or relative not residing with you: ___________________________________________ Your Name________________________________________________ Today’s Date ___________________ ____________________________________________________________________________________________________I. Family of origin history Your Name________________________________________________ Today’s Date ___________________ ____________________________________________________________________________________________________ K. Significant non-marital relationships Person’s age Your age when Your age when L. Children: Indicate those from a previous marriage or relationship with “P” in the last column. Please describe the main difficulty that has brought you to see me: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Your Name________________________________________________ Today’s Date ___________________ ____________________________________________________________________________________________________ N. Treatment 1. Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling services before? 2. Have you ever taken medications for psychiatric or emotional problems? ❑ No ❑ Yes If yes, please indicate: O. Relationships in your family of origin 1. Your parents’ relationship with each other:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Your relationship with each parent and with any other adults present: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Your parents’ medical problems, drug or alcohol use, and mental or emotional difficulties: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. Your relationship with your brothers and sisters, in the past and present: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Your Name________________________________________________ Today’s Date ___________________ ____________________________________________________________________________________________________ If you were abused, please indicate the following. For kind of abuse, use these letters: S = Sexual, such as touching/molesting, fondling, or intercourse N = Neglect, such as failure to feed, shelter, or protect E = Emotional, such as humiliation, etc. 1. How do you get along with your present spouse or partner? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. How do you get along with your children? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Your important friends, past and present: Your Name________________________________________________ Today’s Date ___________________ ____________________________________________________________________________________________________ 1. How many cups of regular coffee do you drink each day? _____ How many cups of tea? ____. How many sodas/pop with caffeine (Coke, Pepsi, Mountain Dew, Dr. Pepper, Orange Crush, etc.)? ____ How many “energy drinks”? ____ How often do you use No Doz or similar caffeine pills? _______ 2. How much tobacco do you smoke or chew each week? ____________________________________________ 3. Have you ever felt the need to cut down on your drinking? ❑ No ❑ Yes 4. Have you ever felt annoyed by criticism of your drinking? ❑ No ❑ Yes 5. Have you ever felt guilty about your drinking? ❑ No ❑ Yes 6. Have you ever taken a morning “eye-opener”? ❑ No ❑ Yes 7. How much beer, wine, or hard liquor do you consume each week, on the average? ________________________ 8. Are there times when you drink to unconsciousness, or run out of money as a result of drinking? ❑ No ❑ Yes 9. Have you ever used inhalants (“huffing”), as glue, gasoline, or paint thinner? ❑ No ❑ Yes If yes, which and when? _________________________________________________________________________ Which drugs (not medications prescribed for you) have you used in the last 10 years? ________________________________________________________________________________________________________________________________________________________________________________________________________ Please provide details about your use of these drugs or other chemicals, such as amounts, how often you used them, their effects, and so forth:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 1. Are you presently suing anyone or thinking of suing anyone? ❑ No ❑ Yes ________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Is your reason for coming to see me related to an accident or injury? ❑ No ❑ Yes If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Are you required by a court, the police, or a probation/parole officer to have this appointment? ❑ No ❑ Yes If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Your Name________________________________________________ Today’s Date ___________________ ____________________________________________________________________________________________________ 4. List all the contacts with the police, courts, and jails/prisons you have had. Include all open charges and pending ones. Under “Jurisdiction,” write in a letter: F = federal, S = state, Co = county, Ci = city.Under “Sentence,” write in the time and the type of sentence you served or have to serve (AR = accelerated or alternate resolution, CS = community service, F = fine, I = incarceration, Pr = probation, Po = parole, O = other, R = restitution). 5. Your current attorney’s name: ________________________________________ Phone: _________________ 6. Are there any other legal involvements I should know about?________________________________________________________________________________________________________________________________________________________________________________________________________ Is there anything else that is important for me as your therapist to know about, and that you have not written about on any of these forms? If yes, please tell me about it here or on another sheet of paper: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Thank you for completing this questionnaire.
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.

Source: http://www.austincounseling.info/yahoo_site_admin/assets/docs/Adult_Intake_Form.339184721.pdf