New Counselee Intake Form

Religious Background

Marriage Information

Marital Status:

Your ages when married:

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)

Family Background:

How many siblings did/do you have?

History Information:

Of the following symptoms or problems that you currently are or have recently experienced, please rate
from 0-5: (0 being not at all, 5 being severe)

How would you describe yourself? (check all that apply):

This portion will be filled out in person at the session:

I regard the information you share with me with the greatest respect, so I want us to be as clear as
possible about how it will be handled. All information that we share as well as my records of our
conversations is confidential. There are three circumstances in which I cannot guarantee confidentiality
either legally or ethically:

  1. If child abuse if suspected, the law requires I report it to the appropriate authorities.
  2. If elder abuse or dependent/impaired adult abuse is suspected, the law requires I report it to
    the appropriate authorities.
  3. If the therapist believes that the client is a clear and imminent danger to self or others, other
    people will be contacted to prevent harm.
  4. In rare circumstances the therapist can be ordered by a Judge to release information (court
    In order to provide you with the best possible help I may consult with other therapists that may
    have 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 Counseling
To allow you to make an informed decision about your treatment, please understand that you may
experience discomfort, such as anger, depression, or frustration during counseling as you remember and
resolve unpleasant events. Seeking to resolve concerns and conflicts between family members, marital
partners, and other people can similarly lead to discomfort as well as relationship changes that may not
be originally intended.
This is not an emergency service. We will not be able to return your calls immediately or schedule
you for immediate treatment. In the event of an emergency, please call 911 or go to the nearest
emergency department.

Counseling has proven, in extensive outcome studies, to be successful in treating and helping
individuals, couples, and families resolve: feelings of depression, failure, anxiety, or loneliness;
unmanageable anger, hostility, or violence; persistent difficulty coping with stresses arising from life
crises, such as death, divorce, acute or chronic illness, or unemployment; persistent problems with a
child’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 marriage
or 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 crucial
that you talk with your counselor about these matters. Please initial this paragraph indicating that you
agree to share any suicidal thoughts or intentions with your counselor at any time they arise, and by
phone 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 situation
deteriorates, we will provide referral to another professional for consultation or treatment.
It is not my mission to speak on behalf of our clients in current or potential court proceedings. In the
event that the counselor is subpoenaed to testify in court on behalf of a client, the client will be
charged, in advance, a fee of $150 per hour for the counselor’s time. (Initials)____________
Counseling sessions are by appointment only. Please give 24-hour notice if you are unable to keep your
appointment. Failure to do so will result in a $20 charge. We are committed to the cultivation of spiritual
and emotional health and overall well-being of those we counsel with.
Normally 8-10 sessions are recommended for counseling effectiveness. However, clients may request more
sessions 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