Please correct the errors described below.
First name/Last Name
Parent name (if applicable)
May we leave you a voicemail?
May we send you text message and email appointment reminders?
Date of Birth
How did you hear about us?
Spouse First Name
Reason for seeking counseling
First goal for therapy
Second goal for therapy
Third goal for therapy
List previous counseling with Counselor name, Year and approx number of sessions including inpatient treatment for mental health or chemical health
Current employment and do you like it
Marriages/Relationships and how is it going currently
• Names/ages of children and any information about them that would be helpful
Siblings and relationship with each
Parents names/ Marital Status/If divorced, how old were you when it happened?
Current Living Situation
Significant Life Events Examples: Serious illness or accident in family, death in family, marriages, divorces, significant financial change
Have you experienced physical, sexual, or emotional abuse? Or/and have you been through an event that feels as though it was traumatic for you at any point in your life?
Medications (list name and dose)
Ever have a head injury as child or adult
Have you ever felt you should cut down on your drinking or drug use? Yes No Maybe
Have people annoyed you by criticizing your drinking or drug use? Yes No
Have you ever felt bad or guilty about your drinking or drug use? Yes No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover? Yes No
Have you had any issues with other substance besides alcohol? Yes No
What role does religion/spirituality play in your life?
Any Current or past Thoughts of Suicide? Yes No
General medical condition: Good Fair Poor
Family History of Mental Health Issues
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