Adult Intake

Insurance ID number

Insurance name, if not listed above

Policy Holders Name and Birthdate

Secondary Insurance

Secondary insurance ID number

First, Middle, Last name

Birth date

Race

Age

Gender

Phone number

Address

City

Zip code

Can we leave you a message

Yes No

Do you want text reminders

Yes No

Email address

Please note: Email correspondence is not considered to be a confidential medium of communication. WE do have HIPPA compliant emails at Northwest Counseling.

Can we email you, including invoices?

Yes No

Can we text invoices to you?

Yes No

Occupation

Place of employment phone number

If needed, is it OK to call your work?

Yes No

Emergency Contact

Emergency contact phone number

Date of first appointment

Have you previously recieved any type of mental health services

Yes No

If yes, which of the following:

Psychotherapy

Medication

Outpatient Hospitalization

Inpatient Hospitalization

If yes, please provde Name of Provider of facility

Dates of treatment

Location

Reason for treatment

Please describe what brings you in today:

When do symptoms first start? Within the last:

30 days 6-12 months 2 years During adolescence During childhood

What areas of your life have been impacted?

Work

School

Home

Self-care

Relationships

Are you currently experiencing overwhelming sadness, grief or depression?

Yes No

If yes, approximately how long?

Are you currently experiencing anxiety, panic of phobias?

Yes No

If yes, approximately how long?

Please describe any major losses or traumas you have experienced:

What significant life changes or stressful events have you experienced recently?

What would you like to accomplish in therapy?

Please list your parents and siblings including age and if decreased age and cause of death

Whom did you live with growing up?

Are your parents married?

Yes No

If your parents divorced, how old were you when they divorced?

Check any family member with substance abuse

Parents

Siblings

Child

Extended family member

Other family member

Spouse

Check any family member with anxiety

Parents

Siblings

Child

Extended family member

Other family member

Spouse

Check any family member with depression

Parents

Siblings

Child

Extended family member

Other family member

Spouse

Any concerns with domestic abuse?

Yes No

Have you witnessed domestic abuse?

Yes No

Have you or anyone in your family had any suicide attempts? Please list:

Any additional diagnosed mental health conditions in your family?

Have you been diagnosed with any mental health conditions? Please list:

Marital status

Never married Domestic partner Married Separated Divorced -- how long (answer in additional comments) Widowed: Please provide partners name and year deceased (answer in additional comments) If married, how long have you been married and what is your partners name? (answer in additional comments)

Additional comments:

Are you currently in a romantic relationship?

Yes No

On a scale 1-10, how would you rate your relationship?

Please list childrens names, ages, name of other parent and if deceased the age and cause of death

Please list any medications and dosage

Primary Physician

Facility

List any specific health problems you are currently experiencing:

If you are having problems with sleep, which phase of sleep are you experiencing issues?

Falling asleep Staying asleep Awakening Early Sleep Apnea

Please list any additional sleep concerns you are experiencing:

How many times per week do you exercise and what kinds of exercise do you get?

Are you currently experiencing any chronic pain?

Yes No

If yes, please describe

Average weekly alcohol intake

None 1-3 drinks 4-8 drinks More than 8

Recreational/Mood enhancing nonprescription drug use

None Daily Weekly Monthly

Type of drug used

None Cannabis Cocaine Painkillers Speed Methamphetamine

In the last year, have you been picked up or charged with a drug-related driving offense?

Yes No

In the last year, have you lost time from school or work because of use?

Yes No

In the last year, have you experienced a medical problem because of use?

Yes No

In the last year, have you been fired from a job because of use and its effects?

Yes No

In the last year, have you felt you ought to cut down on your drinking or drug use?

Yes No

In the last year, have other people annoyed you by criticizing your drinking or drug use?

Yes No

In the last year, have you felt bad or guilty about your drinking or drug use?

Yes No

In the last year, have you had a drink or used drugs as an eye opener first thing in the morning to steady your nerves or get rid of a hangover, or to get the day started?

Yes No

Average Daily nicotine use:

Average daily caffieine use:

Please describe current use of alcohol, cigarettes, and/or recreational drugs:

Please describe previous use of alcohol, cigarettes, and/or recreational drugs:

What do you enjoy about your work (full-time homemaker included)? If retired, what did you enjoy about your work?

What do you find particularly stressful about your current or previous work?

Any concerns with finances, housing and/or transportation? Please list:

What do you enjoy doing in your free time? What do you do to relax?

Do you consider yourself to be spiritual or religious? If yes, please describe your faith or belief:

Do you celebrate traditional holidays/birthdays?

Yes No

What do you consider to be some of your strengths?

What do you consider to be some of your weakness?

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