client intake form · web view2018/06/04 · what led you to end counseling or therapy: in the...
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Catholic Counseling Service
CLIENT INTAKE FORMClient Contact Information Date of First Session _______________
Name: ___________________________________ Email Address: ___________________________________
Cell Phone: ________________________________ Alternative Phone: ________________________________
Home Address: _____________________________________________________________________________
Emergency ContactName: _____________________________ Relationship: __________________Phone: _________________
Address: __________________________________________________________________________________
Client InformationHow did you hear about Catholic Counseling Service: ______________________________________________
Date of Birth: ______________________________ Employment: ____________________________________
Check the highest level of schooling that you have completed:
□ Elementary School □ High School □ College □ Post College □ Trade School □ GED □ Other ___________
Have you served in the military: □ Yes □ No
If yes, what branch: ______________________________ How many years of service: ___________________
Briefly describe your work history:______________________________________________________________
__________________________________________________________________________________________
Have you ever been in trouble with the law: □ Yes □ No
If yes, please explain: ________________________________________________________________________
Are you currently involved in legal problems: □ Yes □ No
If yes: □ Divorce/Separation □ Custody □ Lawsuit □ Parole □ Probation □ Other: _______________
Have you been a victim or perpetrator of abuse: □ Yes □ No
If victim: □ Sexual □ Emotional □ Physical
If perpetrator: □ Sexual □ Emotional □ Physical
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This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.
Catholic Counseling Service
Current Family & Family of Origin History
Marital Status: □ Single □ Committed relationship □ Married □ Separated □ Divorced □ Widowed
How many year(s) have you been in your current marriage or relationship: _____________
Were you previously married: □Yes □ No If yes, how many times: ________________
Was your spouse/partner previously married: □Yes □ No If yes, how many times: ________________
Are you currently sexually active: □ Yes □ No
Do you have trouble in your relationships with others: □ Yes □ No
Please list your children’s name(s), age(s), and occupation(s) including “student”:
Name Age Occupation
__________________________ ________ ________________________________________________ ________ ________________________________________________ ________ ________________________________________________ ________ ______________________
Please list additional person(s) living with you:
Name Age Relationship Occupation
__________________________ ________ ______________________ __________________________________________________ ________ ______________________ __________________________________________________ ________ ______________________ __________________________________________________ ________ ______________________ ________________________
Please list below any physical or emotional health problems that members of your family are currently suffering or suffered in the past—Include relevant extended family such as parents: ____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there a family history of mental illness, attention problems, or addiction? □ Yes □ No
If yes, please explain: ________________________________________________________________________
Medical History2
This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.
Catholic Counseling Service
Are you currently under treatment by a psychiatrist: □ Yes □ No
If yes, Psychiatrist’s Name: ________________________ Psychiatrist’s Phone Number: ___________________Would you sign a release of information to coordinate care with them: □ Yes □ No
Have you ever been diagnosed with a mental disorder: □ Yes □ No If yes, please list any and all diagnoses: _________________________________________________________
When was your last physical exam: ________________
Physician’s Name: ______________________________ Physician’s Phone Number: ______________________ Would you sign a release of information to coordinate care with them: □ Yes □ No
Please list medications below.
Medication Dose/Frequency Length of Time Condition Being Treated
__________________________ __________________ ___________ ____________________________
__________________________ __________________ ___________ ____________________________
__________________________ __________________ ___________ ____________________________
__________________________ __________________ ___________ ____________________________
Please indicate any substances that are recreationally used—outside of a prescribed medication: Type When How Often□ Alcohol □ Past □ Present □ Daily □ Weekly □ Monthly□ Prescription Drugs □ Past □ Present □ Daily □ Weekly □ Monthly□ Marijuana □ Past □ Present □ Daily □ Weekly □ Monthly□ Heroin □ Past □ Present □ Daily □ Weekly □ Monthly□ Cocaine □ Past □ Present □ Daily □ Weekly □ Monthly□ Hallucinogens □ Past □ Present □ Daily □ Weekly □ Monthly□ Other: _______________ □ Past □ Present □ Daily □ Weekly □ Monthly
List your health conditions or illnesses: Note approximate date or age of the onset for each condition/illness.
Health Condition or Illness Age or Date
_______________________________________________________ _________________________________
_______________________________________________________ _________________________________
_______________________________________________________ _________________________________
Reason for CounselingHave you at any point past or present engaged in counseling: □ Yes □ No
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This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.
Catholic Counseling Service
If yes: □ Psychiatrist □ Psychologist □ Social Worker □ Minister □ Counselor □ Other
What led you to end counseling or therapy: ______________________________________________________
In the best way you can, please explain your reason for choosing to begin counseling at this time.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Presenting Problems and ConcernsPlease identify your current symptoms.
□ Addictions
□ Anger/Temper Problems
□ Anxiety
□ Behavior Problems
□ Crying
□ Cutting/Hurting Yourself
□ Depression
□ Eating Problems
□ Fears
□ Financial Problems
□ Hearing Voices/Seeing Things
□ Homicidal Thoughts
□ Inability to Focus/Concentrate
□ Not Accomplishing Work/Tasks
□ Obsessive-Compulsive Behaviors
□ Pornography Problems
□ Parenting Stress
□ Panic Attacks
□ Relationship Problems
□ Sexual Problems
□ Sexual Compulsions
□ Sleep Problems
□ Suicide Attempts
□ Suicidal Thoughts
If your symptom is not listed, please describe:
__________________________________________________________________________________________
__________________________________________________________________________________________
Briefly describe the role religion and spirituality play in your life:
__________________________________________________________________________________________
__________________________________________________________________________________________
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This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.