Adult Intake Form

Personal Information

Please provide the following information and answer the questions below. All information you provide here is protected as confidential information.

Name

First and Last

Date

Parent/Legal Guardian (if under 18):

Address

City

State

Zip Code

Home Phone

Cell/Work/Other Phone

*Please note: Email correspondence is not considered to be a confidential medium of communication

Date of Birth

Age

Gender

Identification Please upload your ID or any form of identification

Add file

Please upload a file

Ethnicity/Race

Native American Hispanic Asian White Black Indian Middle Eastern Other

Marital Status

Never Married Domestic Partnership Married Separated Divorced Widowed

Referred By (if any)

Please list any children & their age

Insurance Information

Insurance Company

Employer

Policy Holder

Relationship

Date of Birth

Insurance Card Please upload both front and back of inurance card

Add file

Please upload a file

History

Who referred you? Or How did you learn of my office?

Previous therapist/practitioner

If yes, please list:

If yes, please list and provide dates:

General and Mental Health Information

1. How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems you are currently experiencing:

2. How would you rate your current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific sleep problems you are currently experiencing:

3. How many times per week do you generally exercise?

What types of exercise do you participate in?

4. Please list any difficulties you experience with your appetite or eating problems:

If yes, for approximately how long?

If yes, when did you begin experiencing this?

If yes, please describe:

9. How often do you engage in recreation drug use?

Daily Weekly Monthly Infrequently Never

If yes, for how long?

11. What significant life changes or stressful events have you experienced lately?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you (e.g. father, grandmother, uncle, etc.)

Family Member

Additional Information

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

If yes, describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

5. What would you like to accomplish out of your time in therapy?

Additional Questions (Couples/Family Therapy only)

1. What are the current concerns in your household/relationship?

2. What do you think it would take to improve the situation?

3. How have you tried to address the problem in the past? What have you tried and were the changes better worse?

Describe the Relationship with your Family/Significant other:

Supportive

Unsupportive

Strained

Not speaking

Too involved

Controlling

Other

Is there anything else you think would be helpful for your counselor to know?

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