Private Counseling Intake Form

Private Counseling


I understand that this information will be kept confidential. *

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Preferred Contact:
Permission to leave a message at this number?

General Information

Gender Identity:
Marital Status:
Education Background:
Spiritual and /or Religious Information
Military History
Payment Preference

Health and Mental Health Information

Permission to Contact?
Permission to Contact?
Are you currently taking any prescription medications?
Have you ever been prescribed psychiatric medication?
How many times per week do you drink alcohol?
How many times per week do you use recreational drugs?
How would you describe the amount of emotional support you receive from others?
I currently receive support from:

Have you ever or are you currently experiencing any of the following?

If yes, please describe. You can include when it started, how often it occurs, and how intense the symptoms are on a scale from 0-10 (with 10 being the highest?)
Caregiver stress
Consistent stress
Depressed mood (if yes, for how long?)
Dramatic mood swings
Eating disorder
Extreme anger
Extreme anxiety
Chronic health problems
Current health problems
Loss of a loved one (Who died and when?)
Loss or transition (i.e. move, retirement, job loss)
Panic or anxiety attacks
Repetitive/obsessive thoughts behaviors
Sense of hopelessness and/or worthlessness
Sleep disturbances
Substance/alcohol abuse
Thoughts of harming another
Thoughts of suicide
Suicide attempt

Additional Information

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