Intake Form (Adult)

Emergency Assistance

If this is an emergency, call:

Crisis Line: 988 (call or text)
911

Client Information

First Name

Last Name

Affirmed/Preferred Name

Date of birth

Gender

Sex at Birth

Sexual Orientation

Ethnicity

Faith Orientation/Spirituality

Contact Information

Phone Number

Email Address

Address

Consent for Contact Select all that apply

Phone/Voicemail

Text

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Mental Health History

Previous Mental Health Diagnoses

Family History of Mental Health Challenges/Diagnoses

Have you previously received therapy?

Yes No

If yes, what is the therapist's name?

Have you previously been prescribed psychiatric medication?

Yes No

If yes, please list medications, dosage, and frequency of dose.

Have you ever been hospitalized for a psychiatric condition or mental health crisis?

Yes No

Please specify any instances of psychological/psychiatric inpatient treatment, including dates and location:

Have you or do you self harm/insure?

Yes No

If yes, please specify method of harm/Injury, frequency, and how long since the last occurrence:

Do you have suicidal thoughts?

Yes, currently Yes, within the last week Previously, within the last month Previously, over one month ago No

Have you ever attempted to die by suicide?

Yes No

Do you have thoughts of hurting others?

Yes, currently Yes, within the last week Previously, within the last month Previously, over one month ago No

Have you ever physically harmed or attempted to harm someone else?

Yes No

Please provide information related to traumatic incidences you have experienced.

Medical History

Do you have any allergies?

Yes No

If yes, please list allergies, reactions, and severity of reactions.

Please provide information on previous or current medical conditions:

Are you pregnant?

Yes No Not sure

If yes, how far along?

Are you postpartum?

Yes No

If yes, how long since the delivery?

How often do you get a full night of sleep?

Regularly Occasionally Never

Do you have a healthy and balanced diet?

Regularly Occasionally No

Do you exercise?

Regularly Occasionally No

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

Is there anything else regarding your medical history that we should be aware of?

Family History

Is there anything regarding your relationships you would like us to be aware of?

Do you have any children?

Yes No

If yes, briefly describe your relationship with your children.

Briefly describe your relationships with your parents.

Do you have any siblings?

Yes No

Briefly describe your relationship with your siblings.

Is there anything else regarding your family history that we should be aware of?

Education/Occupation Information

What is your highest level of education?

Learning difficulties, if any

Current Job Title

Military Service

No Current Active Current Reserve Retired Discharged Child of Service Member Spouse of Service Member

Combat Experience

Yes No

Substance Use Information

Do you use drugs?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

If yes, type and frequency:

If yes, specify smoking or vaping, and frequency:

Do you drink alcohol?

Regularly Occasionally No

Do you drink caffeine?

Regularly Occasionally No

If yes, specify the number of alcoholic drinks per week:

If yes, specify the number of caffeinated drinks per week:

Do you gamble?

Regularly Occasionally No

If yes, specify any negative impacts on your life:

Is there anything else regarding addiction history or concerns that we should be aware of?

Reasons for Visit

Type of Service Needed Please check all that apply

Individual Counseling

Couples Counseling

Polycule Counseling

Family Counseling

Group Counseling

Describe any significant life changes or stressful events that you have recently experienced.

Describe any goals or outcomes you hope to achieve from therapy.

What are your strengths?

Is there anything else you'd like to tell us about?

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