New Counselee Intake Form Name(required) Email(required) Cell Phone(required) Date(required) Address (City, State, Zip)(required) Occupation (required) Birth Date (mm/dd/yyyy)(required) Sex(required) Male Female Education degree(required) High School GED College Degreee Religious Background Did you attend church as a child?(required) Yes No IF Yes, type the name of Church below: Do you attend church currently?(required) Yes No IF Yes, type the name of Church below: How many religious or church-related activities do you attend per month?(required) Do you consider yourself a spiritual person?(required) Yes No Uncertain Do you believe in God?(required) Yes No Uncertain Do you pray to God?(required) Yes No Uncertain How often do you pray?(required) Daily Weekly Not Often How often do you read the bible?(required) Daily Weekly Not Often How often does your family read the bible and/or pray together?(required) Daily Weekly Not Often Explain any recent changes in your religious/spiritual life, if any: Marriage Information Marital Status: Single Divorced Married Remarried Separated Widow/Widower Name of Spouse: Age: Address: (Street, City, State, & Zip Code) Occupation: Phone Number: Religion: Education: High School GED College Is your spouse aware that you are coming for counseling? Yes No Uncertain Is your spouse supportive of you coming for counseling? Yes No Uncertain Is your spouse willing to come for counseling? Yes No Uncertain Have you ever been separated? Yes No When? From: Until: Your ages when married: Husband: Wife Wedding Date: How long did you know your spouse before marriage? Give brief information about any previous marriages for either you or your spouse: Please share any other information you would like me to know about your marriage or your spouse: 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: Child/Dependent: Child/Dependent: Child/Dependent: Child/Dependent: Family Background: If you were raised, or are currently being raised, by someone other than your own parents, briefly explain: How many siblings did/do you have? Older Brothers: Older Sisters: Younger Brothers: Younger Sisters: Identify and describe your primary female caregiver (mother, relative, step mother). List some of her characteristics as a person: Identify and describe your primary male caregiver (father, relative, step father). List some of his characteristics as a person: How did/do your parents or caregivers get along with each other while you were/are in the home? 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.): History Information: Have you dealt with severe emotional struggles in your past? Yes No Have you ever had any therapy or counseling before? Yes No If yes, list counselor or therapist and dates: What was the result of your counseling? 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 Anxiety: Select one option 0 1 2 3 4 5 Panic: Select one option 0 1 2 3 4 5 Depression: Select one option 0 1 2 3 4 5 Apathy: Select one option 0 1 2 3 4 5 Fatigue/Lack of Energy Select one option 0 1 2 3 4 5 Loss of Appetite/Overeating: Select one option 0 1 2 3 4 5 Trouble Sleeping: Select one option 0 1 2 3 4 5 Poor Concentration: Select one option 0 1 2 3 4 5 Feeling Worthless: Select one option 0 1 2 3 4 5 Recent Death: Select one option 0 1 2 3 4 5 Grief Select one option 0 1 2 3 4 5 Chronic Pain: Select one option 0 1 2 3 4 5 Loneliness: Select one option 0 1 2 3 4 5 Fears: Select one option 0 1 2 3 4 5 Shyness: Select one option 0 1 2 3 4 5 Low Self-Esteem Select one option 0 1 2 3 4 5 Lust: Select one option 0 1 2 3 4 5 Mental Problems: Select one option 0 1 2 3 4 5 Other Relational Problems: Select one option 0 1 2 3 4 5 Physical Abuse: Select one option 0 1 2 3 4 5 Emotional Abuse: Select one option 0 1 2 3 4 5 Verbal Abuse: Select one option 0 1 2 3 4 5 Sexual Abuse: Select one option 0 1 2 3 4 5 Sexual Problems: Select one option 0 1 2 3 4 5 Gender Identity Issues: Select one option 0 1 2 3 4 5 Anger: Select one option 0 1 2 3 4 5 Aggressive Behavior: Select one option 0 1 2 3 4 5 Bad Dreams: Select one option 0 1 2 3 4 5 Unwanted Memories: Select one option 0 1 2 3 4 5 Loss of Control: Select one option 0 1 2 3 4 5 Impulsive Behavior: Select one option 0 1 2 3 4 5 Controlling: Select one option 0 1 2 3 4 5 Controlled by Others: Select one option 0 1 2 3 4 5 Obsessive Thoughts: Select one option 0 1 2 3 4 5 Other: Compulsive Behaviors: Select one option 0 1 2 3 4 5 Seeing Things Others Don't See: Select one option 0 1 2 3 4 5 Hearing Voices: Select one option 0 1 2 3 4 5 Racing Thoughts: Select one option 0 1 2 3 4 5 Eating Problems: Select one option 0 1 2 3 4 5 Drug Use: Select one option 0 1 2 3 4 5 Alcohol Use: Select one option 0 1 2 3 4 5 Pregnancy: Select one option 0 1 2 3 4 5 Abortion: Select one option 0 1 2 3 4 5 Legal Matters: Select one option 0 1 2 3 4 5 Work Stress: Select one option 0 1 2 3 4 5 Career Choices: Select one option 0 1 2 3 4 5 Indecisiveness: Select one option 0 1 2 3 4 5 Parenting Problems: Select one option 0 1 2 3 4 5 Financial Problems: Select one option 0 1 2 3 4 5 Spiritual Problems: Select one option 0 1 2 3 4 5 Envy Select one option 0 1 2 3 4 5 Are you currently experiencing any suicidal thoughts? Yes No Have you attempted suicide? Yes No Have you ever been arrested? Yes No Reason: Have you experienced suicidal thoughts in the past? Yes No Are you currently experiencing any violent or homicidal thoughts? Yes No How would you describe yourself? (check all that apply): Self Confident Excitable Likable Anxious Calm Lonely Moody Fearful Bitter Often Sad Introvert Angry Impulsive Extrovert Please describe why you are coming to counseling: (what are your issues, symptoms, how long, etc.) Has anyone been influential, helpful, or harmful related to why you are coming to counseling? What have you personally tried to do about your situation? Has this been helpful? If so, how? If you or your situation were to change for the better, what would that look like to you? What is your biggest regret? What is your greatest achievement? Describe how you think God sees you: Is there any other information you would like to share about yourself or your current circumstances thatwould better help me to understand you? What is your goal for counseling? 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 Book Appointment Δ Share this:TwitterFacebookPinterestEmailLike this:Like Loading...
A Story For His Glory Ministries, Inc. 