Adult and Couples Intake Form

For couples - each complete your own form.

Please correct the errors described below.

This form typically takes between 5 and 15 minutes to complete. It cannot be saved to complete later. If you are coming as a couple, you must each fill out your own copies. This is a confidential and HIPAA compliant encrypted form. The information here will be given to your therapist and uploaded to your personal electronic health record, visible only to your therapist and if applicable, their supervisor. If you have questions about how this information will be used, please call your therapist. If you're using insurance, your insurance company may request your file to determine medical necessity, including this information. Based on this information your therapist may have additional assessments to complete in person. **If there is any information you don't want discussed in front of your partner in the intake, please make a note of that.**

DSM-5 Self rated Level 1 Cross Cutting Symptom Measure Adults

The questions below ask about things that might have bothered you. For each question, mark the number that best describes how much (or how often) you have been bothered by each problem in the PAST TWO WEEKS. 0 - None, not at all 1 - Slight, rare less than a day or two 2 - Mild, several days 3 - Moderate, more than half of days 4 - Severe, nearly every day

e.g., a beer, a 4oz glass of wine, a shot of liquor
e.g., a beer, a 4oz glass of wine, a shot of liquor

Chief complaint or presenting problem

Psychiatric History

Please list past counseling experience including counselor name, dates seeing them, issues that were being addressed, what was the MOST helpful things from that counselor and if you'd like to me contact them. If none - type NONE.
Please list locations, dates, and reason for admittance. If none - type NONE.
Please list providers, dates and substance use addressed. If none, type NONE
Please describe any trauma history, related or unrelated. This may include history of bullying, physical assaults, combat, discrimination, natural disaster, sexual assaults, sexual molestations, life threatening accidents, childhood verbal / emotional / physical abuse, childhood emotional or physical neglect, intimate partner violence.
Is there a family history of depression, anxiety, bipolar, OCD, schizophrenia or substance use on either your mother or father's side of the family?

Medical Issues

Please list the condition, and treatment provider giving support.
What kind, how often, how intense
How much sleep do you usually get and is it restful? Describe any sleep disturbance issues such as sleep apnea, sleep walking, restless leg or disruption from family sleeping situations.
Any situations where you hit your head and lost consciousness or diagnosed head / brain trauma.
Medication name, milligrams, number of pills, how many times a day and prescriber.

Family History

Biological parents, adoptive parents, culture/ethnicity, etc. Are they still married or at what age (yours) did they divorce? Other people important in your upbringing (e.g., step parents, grandparents, etc.)
How was it growing up, did it improve in adulthood.
Please list your siblings from oldest to youngest (include yourself) and how many years older or younger they are. Please note any IMPORTANT step sibling relationships.
Do you have a spiritual / religious community or faith that you want your clinician to consider when working on treatment planning. Do you identify as agnostic or atheist and prefer not have this discussed?

Social History

Please list SIGNIFICANT previous marriage/partner(s), years together and any children
Who is your current partner? Please describe the relationship (married, dating, living together, open, etc). When did you meet? Move in together? Get married?
Please list children and their ages
What, if any current life stressors (e.g., work, unemployment, health issues, parenting, caring for elder parents, etc.) are causing stress in your relationship?

Education and Occupational History

Degree/major, school/university, date graduated.
Formal IEP accommodations or 504 plan.
Please list last 5 years of jobs, dates and reason for leaving.
Please list any past charges, convictions (if any) and sentences.
Divorce, child custody, criminal or drug court, etc. Do any of these issues relate to why you or your partner is in counseling now? Did your lawyer ask you to get counseling? Do you expect that you'll be asking your therapist to have input on these cases?

Your information will be encrypted.