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Confidential Client Intake Information
The information you provide will be kept confidential and will be helpful in planning counseling services for you and/or your child.
Please answer each item to your best ability. Kindly be calm as you go through the 4 sections
1
Personal Information
2
Work & Life
3
Health Data
4
Finally
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Full Name
*
Email
Phone Number
*
Address
Gender
*
Male
Female
Date of Birth
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Current relationship Status
*
Select a Option
Single
Engaged
Married
Separated
Divorced
Widow(er)
Cohabiting
Spouse/Partner's Name
Do you have children?
*
Yes
No
Children's Name(s) & Age
List your your children's names and age below. Click + to add more.
Name
Age
Gender
Male
Female
Are you currently employed?
*
Yes
No
Job Experience
List your job. Click + to add more.
Job Title
Company Name
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Do you have Family Physician & Psychiatrist?
*
Yes
No
Family Physician & Psychiatrist
List your physician name and date of visit. Click + to add more.
Family physician name
Date of last visit
Psychiatrist name
Date of last psychiatrist visit
Do you have any previous or current medical problems?
*
Yes
No
Medical problem.
Current or Previous medical problem.
List your previous or current medical problem. Click + to add more.
Are you currently on any medication?
*
Yes
No
Previous or Current Medications
Please list any prescription medications (dose, frequency) you currently take. Click + to add more.
Current Medication
Previous Medication
Have you had previous counseling?
*
Yes
No
Previous Counseling
Please give the name of the therapist(s), the year(s) you saw them (e.g., 2015 - 2016), and the nature of the difficulty at the time. Click + to add more.
Therapist name
Nature of the difficulty at the time
Date
Have you ever been hospitalized for psychiatric difficulty?
*
Yes
No
Previous Psychiatric difficulty
Please give the year(s) and the nature of the difficulty at the time. Click + to add more.
Nature of Difficulty
Date
Please list any previous or current diagnosis given by a professional
Please check primary reason(s) for seeking counseling:
*
Select an Option
Anxiety
Depression
Grief/loss
Nervousness
Loneliness
Loss of hope
Conflicts at work
Loss of job
Compulsive behavior
Eating/body image
Abuse or assault
Self-esteem
Stress
Alcohol/drug use
Cutting/self-harm
Suicidal thoughts
Anger
Chronic pain
Appetite concerns
Sleep concerns
Legal issues
Marital conflicts
Family conflicts
Relationship conflicts
Gender identity
Sexual/intimacy concerns
Divorce adjustment
Major life transition/change
Other
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1. How severe do you consider your presenting problem/concern(s)?
*
Not severe
Somewhat severe
Moderately severe
Very severe
2. How motivated are you to resolve your presenting problem/concern(s)?
*
Not motivated
Somewhat motivated
Moderately motivated
Very motivated
3. How optimistic are you that your presenting problem/concern(s) can be resolved?
*
Not optimistic
Somewhat optimistic
Moderately optimistic
Very optimistic
What do you hope to achieve from counseling?
*
What other information would you like to share?
*
How did you hear about us?
Freind or Family
Facebook
Physician referral
Client Referral
Therapist
Google
Website
Other
Emergency contact name & Relationship
He/She's Phone Number (answering this is granting us permission to contact in the case of emergency)
Additional information about you
*
I agree to Terms and Conditions..
Submit
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