COUNSELING INTAKE FORM

Name_______________________________________________________Age_________Date__________

Full Address___________________________________________________________________________

______________________________________________________________________________________

Home Phone__________________________Work______________________E-mail______________

Physical History(please be accurate, medical records may need to be disclosed at some point)

General Health_________________________________________________________________________

Are you now under a doctor’s care?________If yes, name of doctor_______________________________

Reason for doctor’s care__________________________________________________________________

Are you taking any medication?___________If yes, what kind?___________________________________

Reason for medication___________________________Last medical examination____________________

Have you ever been hospitalized for a physical illness?____Describe_______________________________

______________________________________________________________________________________

Have you ever been hospitalized for a mental illness?____Describe________________________________

______________________________________________________________________________________

Any recent major illnesses or surgeries?______________________________________________________

Any recurrent or chronic conditions?________________________________________________________

Do you smoke:________Do you take drugs?________If yes, what kind?____________________________

Do you drink?________How much?_________________________________________________________

Any Previous Therapy/Counseling?______If yes, describe, when, where, how long, what for___________

______________________________________________________________________________________

What do you hope to achieve with therapy?___________________________________________________

______________________________________________________________________________________
INTAKE 2

Work History
Occupation_____________________________________________ How long?______________________

If presently unemployed, describe the situation________________________________________________

______________________________________________________________________________________

Hobbies/Avocations______________________________________________________________________

Family Systems Information

Where born______________________________How long there______________Ethnic ID____________

Parents: Father alive____________Where residing____________________Relationship_______________

Mother alive_________Where residing_________________________Relationship___________________

Marital Status________#of marriages__________________Spouse’s name__________________________

Living with a partner_________How long______________Partner’s Name__________________________

Children:#1 M F Age_____ #2 M F Age______ #3 M F Age______#4 M F Age_______#5 M F Age_____

Siblings: Circle your place in the family. If a sibling is deceased, put an X through the placement number.

#1 M F Age____ #2 M F Age____ #3M F Age____ #4 M F Age____ #5 M F Age____ #6 M F Age______

Family Alcoholism or Domestic Violence?________________ Sexual Addictions or Abuse?____________

Parents divorced?___________If yes, what year_____________Your age at the time__________________

If deceased, what year?_________Your age at the time__________Cause of death____________________

Any step-parents?________If yes, describe when and your relationship with them____________________

______________________________________________________________________________________

If reared by someone other than your birth parents, describe the situation in some detail________________

______________________________________________________________________________________

Tell anything else in the space below that you think would be helpful for me, as your therapist, to know.
INTAKE 3

Spiritual History

Religious upbringing_____________________________Present Affiliation_________________________

Is this an important part of your life________Whywhy not_______________________________________

Emotional Status

Are you currently experiencing strong emotions? ____If yes, describe______________________________

______________________________________________________________________________________

Do you make decisions based on your emotions?________How well does that work for you?___________

______________________________________________________________________________________

Did you have what you would consider to be childhood or other traumas?_______If yes, describe________

______________________________________________________________________________________

Have you been treated for emotional disturbances?______If yes, when?_____________________________

Have you had any thoughts of suicide____If so, when___________Do you have any thoughts now_______

Present Situation

Please state why you decided to come for counseling/therapy_____________________________________

What is the nature of your situation__________________________________________________________

______________________________________________________________________________________

What would you like to experience that is different from what you are experiencing now_______________

______________________________________________________________________________________

How long has this been a problem for you____________________________________________________

______________________________________________________________________________________

Please state what you would like to work on in therapy__________________________________________

______________________________________________________________________________________
Personal Agreements

I understand that I may be asked to do certain “homework exercises” such as reading,

I further understand that much of the work done will be to resolve issues and will depend
on my honesty, and willingness to do the things I need to do to move forward even if it is
painful and difficult.

I understand that whatever I say in a session is strictly confidential and will not be
released to anyone without my consent unless I am violating codes of abuse, harm to
myself or others.

I understand that I will pay in full for appointments not canceled with 24 hours notice.
The rate is $65/hr.

______________________________________________________(client signature and

As your therapist/counselor, you honor me by sharing your life and growth with me. I
will not hide myself behind silence or position and will have high regard for you as a
person. I will bring the best that I know from my study and experience. I will bring you
the highest of my insight, wisdom, and spiritual guidance.
I will keep a holistic perspective in our work together because I believe that the Physical,
Spiritual, and Soul (mind, will, emotions) all work together to form the wholly healthy
person.

You can expect truth from me even when you may not want to hear it. I will always have
compassion and empathy for you in all that we do. I value you as a person in need of
care. I will do my best to honor that.

Susan L. Anderson
Susan L. Anderson