Client Intake Form

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Middle Name

Last name

Gender

Female

Male

Trans

Date of birth

Address (Include City, State, and Zip Code)

Home Phone

Cell Phone

Work Phone

Marital Status

Single

Married

Partner

Separated

Divorced

Widowed

Email address

Social Security Number

Insurance Company

Policy Number/Member ID

Group #

Subscribers Name and DOB

Insured's Name and DOB

Primary Care Physician

Psychiatrist/Counselor

Name of person/provider that referred you- If provider, please give clinic and doctor's name

Do you authorize Hope Arising Counseling to release information regarding attending appointments to your PCP/Provider who referred you for services?

Yes No

Are there additional contacts that you give your permission for Hope Arising Counseling to contact regarding your billing, scheduling, or emergencies?

Billing/Scheduling Contact Name

Relationship to Patient

Phone Number

Emergency Contact

Relationship to Patient

Phone Number

Employment/Student Status

What is your current employment or student status?

Full time employee

Part-time employee

Business owner

Full time student

Part-time student

Unemployed

Where do you work?

What is your current job/career?

Where do you attend school?

Highest level of education completed?

What is your desired career?

List all persons currently living in your household and any children not living with you:

Name Age Sex Relationship to you

Please tell us how you hope Hope Arising Counseling can help you.

What are you hoping a counselor can help you with?

How long have these problems been occurring?

How do these problems affect your everyday life (work, relationships, school, physical health, etc)?

For you to feel like treatment was successful, what would need to change in your life?

Please tell us more about your mental health and medical history.

Please list any psychiatric diagnoses you believe apply to your situation and who provided diagnosis (if applicable):

What treatment have you previously received for these conditions (counselors, psychiatrists, approximate dates, etc)?

Have you ever received inpatient care or been hospitalized for mental health treatment (please provide details)?

Have you ever self-harmed or attempted suicide (frequency, date of first / last incidents, etc)?

Are you currently being or have you ever been treated for any other physical conditions or illnesses (including pregnancy)?

Allergies?

Please list all prescribed and over the counter medications/supplements you are currently taking. Please include dosage and prescribing MD/APRN

Please tell us about the important developmental and social details of your life.

Does anyone in your family have a history of mental illness (who, diagnosis, treatment)?

Was there anything abnormal about your birth (premature, complications, parent used illicit drugs, parent took prescription medication(s), etc)?

Did you receive any speech, occupational, or physical therapy (provide details please)?

What hobbies or activities do you currently enjoy or would like to explore?

Is there anything you'd like to share about your relational journey (adoption, divorces, LGBTQ, etc)?

Are you aware of any verbal, physical, emotional or sexual abuse in your family? If yes, please explain.

Have you ever experienced any verbal, physical, emotional or sexual abuse? If yes, please explain.

Are you currently experiencing any verbal, physical, emotional or sexual abuse you previously explained?

Any substantial current or past legal issues or troubles?

Please tell us about your substance use history:

Please upload a photo of your drivers license and the front and back of your insurance card.

Add file

Please upload a file

Credit Card Information

Card Number (No spaces)

Expiration (MO/YR)

CVV (3 digit code on back)

Billing Address (If different from above)

Your typed name below indicates that you have carefully read all pages and agree to all conditions of the informed consent for services, as well as received a copy of our Privacy Practices.

Typed Name

Date

Your information will be encrypted.

Adrea Jones

Licensed Professional Counselor

Adrea Jones is a Licensed Professional Counselor (P1412101) who holds a Master’s degree in Marriage and Family Counseling and Christian Education from Southwestern Baptist Theological Seminary. She strives to provide a safe, accepting, and confidential space for clients to explore their life stories, share their pain, and learn to honor their history while moving forward. She wants her clients to know that therapy is a process and she views her role as a therapist as a supporter, and cheerleader for her clients seeking to make potentially difficult life changes. She desires to help clients improve their self-awareness and discover personal strengths that will lead to personal growth in emotional, mental, and relational health.