Intake Form

Confidential Client Intake Information

The information provided on this form will be kept confidential and will be helpful in planning counseling services for you. Please answer each item to the best of your ability. All information is held in strictest confidence. (Please print clearly.)

Name:

Name you prefer to be called:

Gender:

M F

Date of Birth:

Age:

Home Address:

City:

State:

Zip Code:

Phone Number: (H)

(W)

Cell:

Permission to contact you?

Home Phone Work Phone Cell Phone E-mail* (Please check all that apply)

*Please be aware that the confidentiality of e-mail cannot be guaranteed due to the nature of electronic media. However, all correspondence by e-mail will be treated as private and confidential in the UTEAP/Counseling office.

Legal Guardian / Parent (if under 18):

(PRINT Name of Legal Guardian /Parent and address if different form above)

Who does the child / minor live with?

(Name)

(Relationship)

Address:

City:

State

Zip

Are you a veteran of the U.S. Armed Forces?

Yes No

Are you currently an active reservist

Yes No

Are you living with or in a significant relationship with a veteran or active duty reservist?

Yes No

Religious / denominational preference:

Kindly mention if you choose *Other Racial / Ethnic Identity*

Kindly mention if you choose *Other type of Medical Insurance*

EMERGENCY CONTACT:

Name

Relation

Daytime Phone:

Evening Phone:

Cell Phone:

STATUS FOR ELIGIBILITY OF SERVICES

Please check the appropriate designation(s) and provide the requested information.

EMPLOYEE- please provide the name of the Company/Department/Location:

Company

Department

Location

DEPENDENT- please indicate the name of the employee and their relationship to you.

(Print - Name)

(Relationship)

FAMILY / RELATIONSHIP INFORMATION

Parents:

Mother:

Living Deceased

Age

FAMILY / RELATIONSHIP INFORMATION

Father

Living Deceased

Age

Siblings:

Number of Brothers:

Number of Sisters:

List ages of Brothers:

Names and ages of your children:

Have any of your children passed away?

If yes, when?

PRESENTING PROBLEM / CONCERN(S)

Briefly describe your reasons for seeking counseling:

How long has this been a problem or concern for you?

How has this problem affected your:
*1 = Not at All
-5 = Very Much

Please answer the next three questions:

1. How severe do you consider your present problem / concerns?

Not Severe Somewhat Severe Moderately Severe Very Severe

2. How motivated are you to resolve your problem / concerns?

Mildly Motivated Somewhat Motivated Moderately Motivated Very Motivated

3. How optimistic are you that your problem / concerns can be resolved?

Mildly Optimistic Somewhat Optimistic Moderately Optimistic Very Optimistic

Place a (✓) by any of these statements that are true for you:

I have thoughts of harming myself or others. Thoughts of harming myself or others is a frequent occurrence. I dwell on thoughts of harming myself or others. I have attempted suicide. Approximate date: Means: I have attempted suicide. Approximate date: Means: None of the statements listed about harming myself or others is true for me.

SUBSTANCE USE: IMPACT OF SUBSTANCE / ALCOHOL USE

Alcohol Consumption

Never 1-2 drinks per sitting 3-4 drinks per sitting 5 or more drinks per sitting

Drug Frequency

Please check all that apply:

 Have you felt the need to cut down on your drinking / drug use?  Do you feel annoyed by people complaining about your drinking / drug use?  Do you ever feel guilty about your drinking / drug use?  Do you ever drink an ‘eye-opener’ in the morning to relieve shakes?

BRIEF FAMILY HISTORY

Who in the family?

MEDICAL HISTORY

Name and telephone number of your physician?

When was your last medical examination?

Are you experiencing any physical illnesses or symptoms at this time?

No Yes

Have you had a head injury or been diagnosed with a concussion? If yes, please explain:

List major surgeries or illnesses in the last five years:

Please list ALL medicines you are currently taking, or have taken during the past 6 months (include any medicines that were prescribed by any physician or taken over the counter): >/p>

Name of Medication

Dosage / Frequency

Purpose / Medical Condition

What is your daily caffeine intake?

Never or infrequently 25-60 oz. (3-5 servings) 60+ oz. (5+ servings) 60+ oz. (5+ servings)

PSYCHOLOGICAL HISTORY

Name and telephone number of your psychiatrist, if applicable:

Have you received psychotherapy / counseling, psychiatric hospitalization, and / or chemical dependency treatment in the past?

Yes No (please provide as much information as possible below)

When?

Reason for Counseling:

Name of Therapist:

When?

Reason for Hospitalization:

Hospital:

Please list at least one goal that you would like to accomplish with counseling:

I confirm that I have read, understood and fully reported to the best of my ability all information requested on this form.

Thank you for providing the information requested. Please sign and date below.

Client Signature

Printed Name

Date

Clinician Signature

Printed Name

Date

Confidential Client Intake Information

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