New Client Intake Form (Adult)

Need Emergency Assistance? Please call 911.

Your Name

First Name

First Initial, Last Name

Medical & Psychosocial Information

Hello. The purpose of this form is to collect important information about your history and current symptoms, in your own words.

If yes, please describe the reason for your visit.

Have you seen a counselor before? Outcome of therapy?

Emergency Contact Information

Add another emergency contact

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?

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?

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 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

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)

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.

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

Are you currently having any criminal or legal problems?

Depression Assessment

a. Little interest or pleasure in doing things

b. Feeling down, depressed, or hopeless

c. Trouble falling or staying asleep, or sleeping too much

d. Feeling tired or having little energy

e. Poor appetite or overeating

f. Feeling bad about yourself - or that you are a failure or have let yourself or your family down

g. Trouble concentrating on things, such as reading the newspaper or watching television

h. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

i. Thoughts that you would be better off dead or of hurting yourself in some way

Anxiety Assessment

a. In the last six months have you found it difficult to control worry or anxiety?

b. Does feeling anxious ever impact your relationships or job performance?

c. Does anxiety causes physical symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension or difficulty sleeping?

d. In the last 4 weeks, have you had a panic attack – suddenly feeling fear or panic?

e. Do these attacks bother you a lot or are you worried about having another attack?

f. Do you ever avoid social settings or public places because these settings increase anxiety?

Medical & Mental Health History

Have you ever been diagnosed with a mental health condition?

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, more days than not?

Migraines

Neck and shoulders

Hands or arms

Back

Hips

Reproductive areas

Legs

Feets

My body is pain free most days

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?

Self-Care Habits

How would you describe your eating habits?

Average glasses of water per day?

Rate your stress level:

How minutes do you exercise each week?

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

Sleep Health

Average time you crawl into bed?

Average time it take you to fall asleep?

How many times do you wake during the night?

Total sum awake time during the night

Time you get out of bed?

Do you snore or wake gasping for air?

Do you wake feeling well rested?

Medications

Medication Name & Dose & Duration

Primary Medical Provider

Provider's Name

Preferred Provider Network

Do you want me to coordinate care with your provider?

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?

PAYMENT STUFF All self-pay are due at the time of service. We can provide you with an itemized receipt for submission to a health savings account, by request.   

INSURANCE CLAIMS If your coverage requires a co-payment please bring a means of payment (cash, check, or credit card) to your appointment. Co-insurance or deductible amounts are due after your insurance processes and you receive the explanation of benefits from your insurance carrier. You will receive a bill from Conscious Living Counseling stating the amount due and due date. Our staff will file a claim with your insurance carrier. We will work with you to obtain the benefits you deserve; but, remember, you are accountable for the “patient responsibility” portion of our charges.

QUESTIONS Call the office between 9:00 am and 5:00 pm Monday through Friday. Thank you!

COMMUNICATION CONSENT:

We use HIPAA-compliant technology to reduce wait times, improve the intake process, and ensure that you have access to your provider when needed. We need your consent in order to move forward. Your provider will explain each service in detail. Please call or email if you have questions now.

I consent to receiving text and email notifications for my appointments.

I consent to receive invoices by email, when balance is due.

I consent to HIPAA-compliant texting with my provider, if this is part of my treatment plan.

If it's my request, I consent for credit card charges to apply to my co-pay or balance due with a secured-card using the patient portal.

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

Your message will be encrypted and can only be read by Conscious Living Counseling & Education Center.