Counseling Client Intake Form

Primary Care Physician

Phone:

Street Address:

City

Sate:

Zip Code:

List any current medical problems:

List any current medications:

List any current allergies:

Have you taken medication for a mental health concern? YesNo

Medication Name:

Dates

Was it helpful? YesNo

Medication Name:

Dates

Was it helpful? YesNo

Medication Name:

Dates

Was it helpful? YesNo

Primary Insurance Company

Policyholder’s Name

Group #:

ID #:

Type: HMOPPOMedicare

Other:

Have you previously seen a counselor?

-If yes, who and where:

Approximate dates of counseling

Reason for counseling

Do you have a previous mental health diagnosis?

-If yes, describe:

What did you find most helpful in therapy?

What did you find least helpful in therapy?

Have you used psychiatric services before?

What are the main issues for which you are seeking counseling?

When did these issues first start?

What results would you like to get from counseling?

What is the most concerning issue for you right now?

Please select the severity of EACH of the following concerns:
Alcohol use Anger issues Anorexia Anti-social behavior Anxiety / paranoia Appetite changes Bi-polar behavior Binging / purging Binging / purging Crying Decreased sex drive Drug use Excessive worrying Fear of death Headaches / migraines Hopelessness Hyperactivity Impulsivity Inability to focus Indecisiveness Low energy Low self-worth Nausea / indigestion Nightmares Panic attacks Poor concentration Problems at home Racing thoughts Restlessness Sadness Self-mutilation Self-mutilation Sleep deprivation Spiritual concerns Suicidal thoughts Trauma flashbacks Unresolved guilt Weight (over or under) Work issues Workaholic (working too much)