Intake Form (Adult)

Intake Form

The purpose of this form (Intake Form) is to collect important information about your history and current symptoms, in your own words. We'll collect the basics, as well as information about your mental wellbeing, and your relational health. Please try to describe your situation as accurately as possible. Thank you!

A.

Please describe the reason for your visit.

Have you seen a counselor before? Please describe the outcome?

Emergency Contact Information

Add another emergency contact

B. Relationship History

Please describe your immediate family.

Are you currently in a partnered/married relationship? If so, how long?

Name(s) and age(s) of your children? Or important children in your life.

Are your parents still together? If no, how old were you when they divorced/separated?

How would you describe your primary maternal (female) figure growing up?

Secure, predictable, and calm.

Anxious, protective, or intense.

Confusing, inconsistent, or immature.

Absent.

Not applicable.

How would you describe your primary paternal (male) figure growing up?

Secure, predictable, and calm.

Anxious, protective, or intense.

Confusing, inconsistent, or immature.

Absent.

Not applicable.

If you are partnered, how would you describe YOUR attachment pattern toward your partner?

Secure, predictable, and calm.

Anxious, protective, or intense.

Confusing, inconsistent, or immature.

Absent.

Not applicable.

How would you describe your inner relationship to Self:

How do you experience yourself? Do you experience any heightened sensitivity with any sense (such as hearing or touch)? What's your relationship to the world? How do you experience the world? How do you move through the world, in your inner world? No right or wrong answer.

C. Trauma & Loss History

Are there any special circumstances that have impacted your upbringing or development?

Have there been any traumatic experiences that have impacted your life?

Has there been a history or current concern about physical or sexual abuse in your life?

D. Learning & Education

Highest level of education completed?

Where? When did you or will you graduate?

Have you ever been diagnosed with a learning disability?

ADHD/Attention

Math

Reading

Comprehension

Retaining new information

Do you know your "go-to" learning style? You'll benefit from practicing a variety of learning techniques, though, so we'll focus on both learning techniques and retrieving information when you need it the most!

I prefer written materials

I prefer verbal instructions

I prefer a demonstration before doing

I need context to understand new info

I prefer audiobooks or podcasts

E. Employment History

Where you are currently employed? How long have you been with your employer?

How would you describe your job satisfaction? (low, medium, high)

F. Social Relationships

This may be a difficult question to answer, but please try your best. Please describe you social connection:

I have lots of close friends and family.

I don't have much family, but many friends.

I have a handful of close relationships either friends or family.

I have at least two close people in my life.

I have little support and feel lonely often.

I have little support but rarely feel lonely.

Please describe your relationship with your closest friend? (Non-family)

Secure, predictable, and calm.

Anxious or intense.

Confusing or inconsistent.

Guarded.

Lost contact/neglected relationship.

Not applicable.

Please describe your strengths in friendship and one area you believe is a challenge. (Example: I enjoy making my friends laugh; I don't always return calls.)

Do you identify with any cultural/ethnicity and/or religion?

Are you currently having any criminal or legal problems?

G. Depression Assessment

Do you experience any of the following? Use the dropdown menu and select the best option.

Check all that apply to you:

My low mood has been present everyday, for at least 2 weeks.

I've experienced low mood, most days, for the last two years or longer.

I have struggled with seasonal depression during the winter season.

(Female) I experience low mood 7-12 days before my period.

I have highs and lows with my mood, or other people have expressed concern that I have highs and lows.

I feel depressed after a period of high anxiety.

I've experienced a major change or loss in my life, when I think about it, I can get really low.

I tend to ruminate about the past.

H. Anxiety Assessment

Executive Function Skills

I. Medical & Mental Health History

Condition

Year Diagnosed

Condition

Year Diagnosed

Condition?

Year Diagnosed

Are you currently managing any physical medical conditions?

Do you struggle with pain in any area of your body?

Migraines

Neck and shoulders

Hands or arms

Back

Hips

Reproductive areas

Legs

Feets

My body is pain free most days

J. Hormone/Reproductive Health

If female, are you taking birth control? Did problems worsen or improve after starting?

If female, are you still menstruating? Date of last period?

If female, are you experiencing any reproductive concerns?

K. Self-Care Habits

Please describe your alcohol and substance use: (It's Ok, you can be honest.)

L. Sleep Health

Average time you crawl into bed?

Time you get out of bed?

M. Medications

Medication Name & Dose & Duration

N. Primary Medical Provider

Provider's Name

Preferred Provider Network

I am currently being treated for:

Blood pressure concerns

Blood sugar concerns

Hormone concerns

Autoimmune Illness

Pain management

Anything else we should know about you or your concerns?

I consent to the use of digital communication the use of digital forms.

Thank you!

Your information will be encrypted.

Intake Form (Adult)

HIPAA-COMPLIANT FORM

Intake Form

A.

Emergency Contact Information

B. Relationship History

C. Trauma & Loss History

D. Learning & Education

E. Employment History

F. Social Relationships

G. Depression Assessment

H. Anxiety Assessment

Executive Function Skills

I. Medical & Mental Health History

J. Hormone/Reproductive Health

K. Self-Care Habits

L. Sleep Health

M. Medications

N. Primary Medical Provider

HIPAA-COMPLIANT FORM