New Counselee Intake Form Go backYour message has been sent Name(required) Warning Email(required) Warning Cell Phone(required) Warning Date (YYYY-MM-DD)(required) Warning Address (City, State, Zip)(required) Warning Occupation (required) Warning Birth Date (mm/dd/yyyy)(required) Warning Sex(required) Male Female Warning Education degree(required) High School GED College Degreee Warning Religious Background Did you attend church as a child?(required) Yes No Warning IF Yes, type the name of Church below: Warning Do you attend church currently?(required) Yes No Warning IF Yes, type the name of Church below: Warning How many religious or church-related activities do you attend per month? (YYYY-MM-DD)(required) Warning Do you consider yourself a spiritual person?(required) Yes No Uncertain Warning Do you believe in God?(required) Yes No Uncertain Warning Do you pray to God?(required) Yes No Uncertain Warning How often do you pray?(required) Daily Weekly Not Often Warning How often do you read the bible?(required) Daily Weekly Not Often Warning How often does your family read the bible and/or pray together?(required) Daily Weekly Not Often Warning Explain any recent changes in your religious/spiritual life, if any: Warning Marriage Information Marital Status: Single Warning Divorced Warning Married Warning Remarried Warning Separated Warning Widow/Widower Warning Name of Spouse: Warning Age: Warning Address: (Street, City, State, & Zip Code) Warning Occupation: Warning Phone Number: Warning Religion: Warning Education: High School GED College Warning Is your spouse aware that you are coming for counseling? Yes No Uncertain Warning Is your spouse supportive of you coming for counseling? Yes No Uncertain Warning Is your spouse willing to come for counseling? Yes No Uncertain Warning Have you ever been separated? Yes No Warning When? From: Warning Until: Warning Your ages when married: Husband: Warning Wife Warning Wedding Date: Warning How long did you know your spouse before marriage? Warning Give brief information about any previous marriages for either you or your spouse: Warning Please share any other information you would like me to know about your marriage or your spouse: Warning Children and Dependent Information: Please list below information about all of your children, and any dependents currently in your care: (Name, Age, Sex, Relationship, Living, Education, Married, Lives with you) Child/Dependent: Warning Child/Dependent: Warning Child/Dependent: Warning Child/Dependent: Warning Child/Dependent: Warning Family Background: If you were raised, or are currently being raised, by someone other than your own parents, briefly explain: Warning How many siblings did/do you have? Older Brothers: Warning Older Sisters: Warning Younger Brothers: Warning Younger Sisters: Warning Identify and describe your primary female caregiver (mother, relative, step mother). List some of her characteristics as a person: Warning Identify and describe your primary male caregiver (father, relative, step father). List some of his characteristics as a person: Warning How did/do your parents or caregivers get along with each other while you were/are in the home? Warning Please share any other information you would like for me to know about your past or current family(I.e., history of emotional or mental disorder or suicide, alcoholism, excessive drug use, significanttrauma, etc.): Warning History Information: Have you dealt with severe emotional struggles in your past? Yes No Warning Have you ever had any therapy or counseling before? Yes No Warning If yes, list counselor or therapist and dates: Warning What was the result of your counseling? Warning Of the following symptoms or problems that you currently are or have recently experienced, please ratefrom 0-5: (0 being not at all, 5 being severe) Stress: Select one option 0 1 2 3 4 5 Warning Anxiety: Select one option 0 1 2 3 4 5 Warning Panic: Select one option 0 1 2 3 4 5 Warning Depression: Select one option 0 1 2 3 4 5 Warning Apathy: Select one option 0 1 2 3 4 5 Warning Fatigue/Lack of Energy Select one option 0 1 2 3 4 5 Warning Loss of Appetite/Overeating: Select one option 0 1 2 3 4 5 Warning Trouble Sleeping: Select one option 0 1 2 3 4 5 Warning Poor Concentration: Select one option 0 1 2 3 4 5 Warning Feeling Worthless: Select one option 0 1 2 3 4 5 Warning Recent Death: Select one option 0 1 2 3 4 5 Warning Grief Select one option 0 1 2 3 4 5 Warning Chronic Pain: Select one option 0 1 2 3 4 5 Warning Loneliness: Select one option 0 1 2 3 4 5 Warning Fears: Select one option 0 1 2 3 4 5 Warning Shyness: Select one option 0 1 2 3 4 5 Warning Low Self-Esteem Select one option 0 1 2 3 4 5 Warning Lust: Select one option 0 1 2 3 4 5 Warning Mental Problems: Select one option 0 1 2 3 4 5 Warning Other Relational Problems: Select one option 0 1 2 3 4 5 Warning Physical Abuse: Select one option 0 1 2 3 4 5 Warning Emotional Abuse: Select one option 0 1 2 3 4 5 Warning Verbal Abuse: Select one option 0 1 2 3 4 5 Warning Sexual Abuse: Select one option 0 1 2 3 4 5 Warning Sexual Problems: Select one option 0 1 2 3 4 5 Warning Gender Identity Issues: Select one option 0 1 2 3 4 5 Warning Anger: Select one option 0 1 2 3 4 5 Warning Aggressive Behavior: Select one option 0 1 2 3 4 5 Warning Bad Dreams: Select one option 0 1 2 3 4 5 Warning Unwanted Memories: Select one option 0 1 2 3 4 5 Warning Loss of Control: Select one option 0 1 2 3 4 5 Warning Impulsive Behavior: Select one option 0 1 2 3 4 5 Warning Controlling: Select one option 0 1 2 3 4 5 Warning Controlled by Others: Select one option 0 1 2 3 4 5 Warning Obsessive Thoughts: Select one option 0 1 2 3 4 5 Warning Other: Warning Compulsive Behaviors: Select one option 0 1 2 3 4 5 Warning Seeing Things Others Don’t See: Select one option 0 1 2 3 4 5 Warning Hearing Voices: Select one option 0 1 2 3 4 5 Warning Racing Thoughts: Select one option 0 1 2 3 4 5 Warning Eating Problems: Select one option 0 1 2 3 4 5 Warning Drug Use: Select one option 0 1 2 3 4 5 Warning Alcohol Use: Select one option 0 1 2 3 4 5 Warning Pregnancy: Select one option 0 1 2 3 4 5 Warning Abortion: Select one option 0 1 2 3 4 5 Warning Legal Matters: Select one option 0 1 2 3 4 5 Warning Work Stress: Select one option 0 1 2 3 4 5 Warning Career Choices: Select one option 0 1 2 3 4 5 Warning Indecisiveness: Select one option 0 1 2 3 4 5 Warning Parenting Problems: Select one option 0 1 2 3 4 5 Warning Financial Problems: Select one option 0 1 2 3 4 5 Warning Spiritual Problems: Select one option 0 1 2 3 4 5 Warning Envy Select one option 0 1 2 3 4 5 Warning Are you currently experiencing any suicidal thoughts? Yes No Warning Have you attempted suicide? Yes No Warning Have you ever been arrested? Yes No Warning Reason: Warning Have you experienced suicidal thoughts in the past? Yes No Warning Are you currently experiencing any violent or homicidal thoughts? Yes No Warning How would you describe yourself? (check all that apply): Self Confident Warning Excitable Warning Likable Warning Anxious Warning Calm Warning Lonely Warning Moody Warning Fearful Warning Bitter Warning Often Sad Warning Introvert Warning Angry Warning Impulsive Warning Extrovert Warning Please describe why you are coming to counseling: (what are your issues, symptoms, how long, etc.) Warning Has anyone been influential, helpful, or harmful related to why you are coming to counseling? Warning What have you personally tried to do about your situation? Has this been helpful? If so, how? Warning If you or your situation were to change for the better, what would that look like to you? Warning What is your biggest regret? Warning What is your greatest achievement? Warning Describe how you think God sees you: Warning Is there any other information you would like to share about yourself or your current circumstances thatwould better help me to understand you? Warning What is your goal for counseling? Warning This portion will be filled out in person at the session: ConfidentialityI regard the information you share with me with the greatest respect, so I want us to be as clear aspossible about how it will be handled. All information that we share as well as my records of ourconversations is confidential. There are three circumstances in which I cannot guarantee confidentialityeither legally or ethically: If child abuse if suspected, the law requires I report it to the appropriate authorities. If elder abuse or dependent/impaired adult abuse is suspected, the law requires I report it tothe appropriate authorities. If the therapist believes that the client is a clear and imminent danger to self or others, otherpeople will be contacted to prevent harm. In rare circumstances the therapist can be ordered by a Judge to release information (courtorder).In order to provide you with the best possible help I may consult with other therapists that mayhave insights that will be of assistance, but only in such a way that your confidentiality is preserved.Otherwise, I will not tell anyone about your treatment, diagnosis, history, or even that you are a client,without your full knowledge and a signed “Release of Information Form.” The Risks of CounselingTo allow you to make an informed decision about your treatment, please understand that you mayexperience discomfort, such as anger, depression, or frustration during counseling as you remember andresolve unpleasant events. Seeking to resolve concerns and conflicts between family members, maritalpartners, and other people can similarly lead to discomfort as well as relationship changes that may notbe originally intended.This is not an emergency service. We will not be able to return your calls immediately or scheduleyou for immediate treatment. In the event of an emergency, please call 911 or go to the nearestemergency department. BENEFITS OF COUNSELINGCounseling has proven, in extensive outcome studies, to be successful in treating and helpingindividuals, couples, and families resolve: feelings of depression, failure, anxiety, or loneliness;unmanageable anger, hostility, or violence; persistent difficulty coping with stresses arising from lifecrises, such as death, divorce, acute or chronic illness, or unemployment; persistent problems with achild’s behavior, school adjustment, or performance; chronic work difficulties or frequent job changes;alcohol or drug abuse; repeated financial difficulties; persistent feelings of dissatisfaction with marriageor family life; sexual concerns; and drastic weight fluctuations or irregular eating patterns. SUICIDAL THINKING AND BEHAVIOR If you are suicidal during the course of your counseling, it is crucialthat you talk with your counselor about these matters. Please initial this paragraph indicating that youagree to share any suicidal thoughts or intentions with your counselor at any time they arise, and byphone if they occur in between sessions. (Initials) TERMINATION OF THERAPY You may leave therapy at any time. If you decide to discontinue counseling,please discuss your decision with your counselor. If a situation fails to improve or a situationdeteriorates, we will provide referral to another professional for consultation or treatment.COURT PROCEEDINGSIt is not my mission to speak on behalf of our clients in current or potential court proceedings. In theevent that the counselor is subpoenaed to testify in court on behalf of a client, the client will becharged, in advance, a fee of $150 per hour for the counselor’s time. (Initials)____________FEES AND APPOINTMENTSCounseling sessions are by appointment only. Please give 24-hour notice if you are unable to keep yourappointment. Failure to do so will result in a $20 charge. We are committed to the cultivation of spiritualand emotional health and overall well-being of those we counsel with.Normally 8-10 sessions are recommended for counseling effectiveness. However, clients may request moresessions if they so wish and are free at any time to terminate if they so desire. I give my consent for treatment for myself or my child,_______________________, I understand all of the above sections that I have initialed,and agree to pay for services when received. __________________________ Client signature Date __________________________ Signed (spouse, child, or other) Date Counselor’s signature Date Warning. Book AppointmentSubmitting form Δ Share this: Click to share on X (Opens in new window) X Click to share on Facebook (Opens in new window) Facebook Click to share on Pinterest (Opens in new window) Pinterest Click to email a link to a friend (Opens in new window) Email Like Loading...
A Story For His Glory Ministries, Inc. 