Adult Intake Form

Instructions: To assist us in helping you, please fill out this form as fully and openly as possible. All private information is held in the strictest confidence within legal limits. If certain questions do not apply to you, leave them blank.

Adult Intake Form

Name*
First Last
Age*
Please enter a number from 18 to 120.
Gender*
- Male
- Female
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Weight
Height
Eye Color
Hair Color
Race
Today's Date*
Date Format: MM slash DD slash YYYY
Date Of Birth*
Education Level*
- Less Than high School
- Highschool/ GED
- Some College
- 2 Year College (Associates Degree)
- 4 Year College (BA/BS Degree)
- Doctoral Degree
- Professional Degree (e.g., MD or JD)
Occupation
Home Phone*
Business Phone
Present Marital Status*
- never married
- engaged to be married
- married now for first time
- married now after first time
- seperated
- divorced and not remarried
- widowed and not remarried
If Married, Are You Presently Living With Your Spouse?
- Yes
- No
If Married, Years Married To Present Spouse:
Please enter a number from 0 to 100.
Are You Presently Receiving Counseling Services?*
- Yes
- No
If Yes, Please Briefly Describe
Have You Received Counseling In The Past?*
- Yes
- No
If Yes, Please Briefly Describe
What Is (Are) Your Main Reason(s) For This Visit?*
How Long Has This Problem Persisted?
Under What Conditons Do Your Problems Usually Get Worse?
Under What Conditons Do Your Problems Usually Improve?
How Did You Hear About This Clinic, Or Who Referred You?
Medical History
Physician's Name
First Last
Physician's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
List Any Major Illnesses And/Or Operations You Have Had:
List Any Physical Concerns You Are Presently Having: (e.g. High Blood Pressure, Headaches, Dizziness, etc.)
List Any Other Physical Concerns You Have Experienced In The Past:
When Was Your Last Complete Physical Exam?*
Results Of Physical Exam:
On Average How Many Hours Of Sleep Do You Get Daily?*
Do You Have Trouble Falling Asleep At Night?*
- Yes
- No
If Yes, Describe:
Have You Gained/Lost Over Ten Pounds In The Past Year?*
- Yes
- No
If Yes, Was The Gain/Loss On Purpose?
- Yes
- No
Describe Your Appetite (During The Past Week)*
- Poor Appetite
- Average Appetite
- High Appetite
What Medications (And Dosages) Are You Taking Presently, And For What Purpose?
Religious Concerns
What Is Your Present Religious Affiliation*
- Catholic
- Jewish
- Protestant
- Baptist
- None, But I Believe In God
- Athiest Or Agnostic
How Important Is Religious Commitment To You?
- 1 - Unimportant
- 2
- 3
- 4 - Average Importance
- 5
- 6
- 7 - Extremely Important
Do You Desire Having Your Religious Beliefs And Values Incorporated Into The Counseling Process?*
- No
- Yes
- Not Sure
If Yes Please Explain:
Family History
Mother's Age
Please enter a number from 13 to 120.
If Deceased, How Old Were You When She Died?
Please enter a number from 0 to 120.
Father's Age
Please enter a number from 13 to 120.
If Deceased, How Old Were You When He Died?
Please enter a number from 0 to 120.
If Your Parents Are Divorced, How Old Were You Then?
Please enter a number from 0 to 120.
Number Of Brothers And Their Ages:
Number Of Sisters And Their Ages:
I Was Child Number:*
Please enter a number from 1 to 25.
In A Family Of ____ Children.*
Please enter a number from 1 to 25.
Were You Adopted Or Raised With Parents Other Than Your Natural Parents?*
- Yes
- No
Briefly Describe Your Relationship With Your Brothers And/Or Sisters:
Which Of The Following Best Describes The Family In Which You Grew Up?*
- 1 - Warm And Accepting
- 2
- 3
- 4
- 5 - Average
- 6
- 7
- 8
- 9 - Hostile And Fighting
Which Of These Describes The Way In Which Your Family Raised You?*
- 1 - Allowed Me To Be Very Independent
- 2
- 3
- 4
- 5 - Average
- 6
- 7
- 8
- 9 - Attempted To Control Me
Your Mother
Briefly Describe Your Mother (Or Mother Substitute):*
How Did She Discipline You?
How Did She Reward You?
How Much Time Did She Spend With You When You Were A Child?*
- Much
- Average
- Little
Your Mother's Occupation When You Were A Child:
- Stayed Home
- Worked Outside Part-Time
- Worked Inside Full-Time
How Did You Get Along With Your Mother When You Were A Child?
- Poorly
- Average
- Well
How Do You Get Along With Your Mother Now?
- Poorly
- Average
- Well
Did Your Mother Have Any Problems (e.g. Alcoholism, Violence, etc.) Which May Have Affected Your Childhood Development?*
- Yes
- No
If Yes, Please Describe:
Is There Anything Unusual About Your Relationship With Your Mother?*
- Yes
- No
If Yes, Please Describe:
How Well Did Your Mother Treat You Growing Up?
- 1 - Poor
- 2
- 3
- 4 - Average
- 5
- 6
- 7 - Excellent
How Well Did Your Mother Treat Your Family Growing Up?
- 1 - Poor
- 2
- 3
- 4 - Average
- 5
- 6
- 7 - Excellent
How Well Did Your Mother Treat Your Father Growing Up?
- 1 - Poor
- 2
- 3
- 4 - Average
- 5
- 6
- 7 - Excellent
Your Father
Briefly Describe Your Father (Or Father Substitute):*
How Did He Discipline You?
How Did He Reward You?
How Much Time Did He Spend With You When You Were A Child?*
- Much
- Average
- Little
Your Father's Occupation When You Were A Child:
- Stayed Home
- Worked Outside Part-Time
- Worked Inside Full-Time
How Did You Get Along With Your Father When You Were A Child?
- Poorly
- Average
- Well
How Do You Get Along With Your Father Now?
- Poorly
- Average
- Well
Did Your Father Have Any Problems (e.g. Alcoholism, Violence, etc.) Which May Have Affected Your Childhood Development?*
- Yes
- No
Is There Anything Unusual About Your Relationship With Your Father?*
- Yes
- No
If Yes, Please Describe:
How Well Did Your Father Treat You Growing Up?
- 1 - Poor
- 2
- 3
- 4 - Average
- 5
- 6
- 7 - Excellent
How Well Did Your Father Treat Your Family Growing Up?
- 1 - Poor
- 2
- 3
- 4 - Average
- 5
- 6
- 7 - Excellent
How Well Did Your Father Treat Your Mother Growing Up?
- 1 - Poor
- 2
- 3
- 4 - Average
- 5
- 6
- 7 - Excellent
How Often Do The Following Thoughts Occur To You:
Life Is Hopeless*
- Never
- Rarely
- Sometimes
- Frequently
I Am Lonely*
- Never
- Rarely
- Sometimes
- Frequently
No One Cares About Me*
- Never
- Rarely
- Sometimes
- Frequently
I Am A Failure*
- Never
- Rarely
- Sometimes
- Frequently
Most People Don't Like Me*
- Never
- Rarely
- Sometimes
- Frequently
I Want To Die*
- Never
- Rarely
- Sometimes
- Frequently
I Want To Hurt Someone*
- Never
- Rarely
- Sometimes
- Frequently
I Am So Stupid*
- Never
- Rarely
- Sometimes
- Frequently
I Am Going Crazy*
- Never
- Rarely
- Sometimes
- Frequently
I Can't Concentrate*
- Never
- Rarely
- Sometimes
- Frequently
I Am So Depressed*
- Never
- Rarely
- Sometimes
- Frequently
God Is Disappointed In Me*
- Never
- Rarely
- Sometimes
- Frequently
I Can't Be Forgiven*
- Never
- Rarely
- Sometimes
- Frequently
Why Am I So Different?*
- Never
- Rarely
- Sometimes
- Frequently
I Can't Do Anything Right*
- Never
- Rarely
- Sometimes
- Frequently
People Hear My Thoughts*
- Never
- Rarely
- Sometimes
- Frequently
I Have No Emotions*
- Never
- Rarely
- Sometimes
- Frequently
Someone Is Watching Me*
- Never
- Rarely
- Sometimes
- Frequently
I Hear Voices In My Head*
- Never
- Rarely
- Sometimes
- Frequently
I Am Out Of Control*
- Never
- Rarely
- Sometimes
- Frequently
Please Comment ( e.g. Examples, Frequency, Duration, Effects On You) About Each Of The Above Thoughts Which Occur Frequently Or Are A Concern To You.
Check The Behaviors And Symptoms Which Occur To You More Often Than You Would Like Them To Take Place:
- Aggression
- Alcohol Dependence
- Anger
- Antisocial Behavior
- Anxiety
- Avoiding People
- Chest Pain
- Depression
- Disorientation
- Distractibility
- Dizziness
- Drug Dependence
- Eating Disorder
- Elevated Mood
- Fatigue
- Hallucinations
- Heart Palpitations
- High Blood Pressure
- Hopelessness
- Impulsivity
- Irritability
- Judgement Errors
- Loneliness
- Memory Impairment
- Mood Shifts
- Panic Attacks
- Phobias/ Fears
- Recurring Thoughts
- Sexual Difficulties
- Sick Often
- Sleeping Problems
- Speech Problems
- Suicidal Thoughts
- Thoughts Disorganized
- Trembling
- Withdrawing
- Worrying
- Other (Specify Below)
Please Give Examples Of How Each Of These Which You Checked Impair Your Ability To Function (e.g., Socially, Emotionally, Occupationally, Physically, etc.).
List Your Five Greatest Strengths:
List Your Five Greatest Weaknesses:
List Your Main Social Difficulties:
List Your Main Love And Sex Difficulties:
List Your Main Difficulties At School Or Work:
List Your Main Difficulties At Home:
List Your Behaviors Which You Would Like To Change:
Additional Information You Believe Would Be Helpful:

Adult Intake Form

Medical History

Religious Concerns

Family History

Your Mother

Your Father

How Often Do The Following Thoughts Occur To You: