TDNT Counseling Services Intake Form
Complete the intake form for your TDNT Counseling Services sessions. We encourage you to complete as many fields as possible to help us provide you with the best clinical care and treatment. We will retain a copy on file to begin your treatment. To update your information, please contact us or your assigned therapist anytime at tdntcounseling@tdntsocialservices.org.
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TDNT Social Services, Inc. (TDNT Counseling Services Program)
TDNT Social Services, Inc.
Client Information (Required)
Legal First Name *
Legal Middle Name
Legal Last Name *
Preferred or Chosen Name
Date of Birth (mm/dd/yyyy) *
Email *
Mobile Phone Number *
Residential Address (street, city, state, zip) *
Emergency Contact Name: *
Emergency Contact Phone Number *
Emergency Contact Relationship to You *
Your Age *
Gender /Sex *
Preferred Pronouns
Clear selection
Sexual Orientation *
Current Marital Status *
Current Romantic Relationship Status *
Current Romantic Relationship Type *
How many children do you have? *
List your children's age, sex and first name, and whether they are biological or nonbiological (birthed, adopted, surrogate, etc). *
How would you describe your family, romantic and social relationships? Any stressors? *
Race *
Ethnicity *
Religion *
Required
Highest Education Level *
Name of Previous and/or Current School & Major, if applicable *
Do you work? Where? Position/Job title? Previous work history? *
Annual Income *
What is your current housing status and living arrangement? *
How would you describe your financial status and work relationships? Any stressors? *
What is your HIV status? *
What is your Hepatitis B or C status *
Do you use cigarettes, marijuana, alcohol or other drugs and substances? Please list the name of each substance you currently use or that you have used in the past including recreational or not prescribed drugs; list how you use them (smoke, vape, inhale, snort, eat, swallow, drink, etc), the amount and frequency of use (one 10mg pill once a week, 5 grams twice a year, one cigar-size blunt a day, etc) and when was the last time and date you used each substance. *
Do you have any current medical condition(s) or diagnosis(es) not already disclosed on this form? Please list all medical conditions you currently have. *
Are you currently taking any medications? Please list all names of medications, why you are taking these medications, the dosage and frequency and indicate whether the medication is prescribed or not. *
Who is your current and most recent physician, doctor and/or psychiatrist? Please list the first and last names, phone numbers, practice address, and email/fax number. *
Do you have any current disabilities, impairment, language barriers or other barriers? Do you require additional support for those? *
Have you had previous counseling? *
If yes, what dates did you attend counseling previously? *
If yes, what is the first and last name of your previous counselor? *
If yes, why did you attend counseling previously, and what made you stop going? *
What is the reason for connecting with or scheduling your appointment with TDNT Counseling Services today? *
Are you seeking Individual, Couples or Group Therapy? *
List any concerns you have (anxiety, anger management, stress management, need for general support, grief, decompress about daily stressors, relationship issues, etc.) *
Did someone else other than yourself refer you for services? Please list the full name and contact information of the referring physician or referring party? Include phone number, address and email/fax. *
Have you ever engaged in self-harm or self-injurious behaviors including self-cutting, body mutilation, hitting or head banging, or intentionally engaging in other risky behaviors to self-harm including over-eating, starvation, using drugs, being sexually promiscuous without using safety measures, reckless driving, among other unsafe behaviors? If so, please describe those, the frequency and the last time/date you've engaged in those behaviors? *
Have you ever thought about or attempted to die by suicide (past or present)?
Clear selection
If yes, when was the last date you had these thoughts to die by suicide or you attempted to die by suicide? (m/d/yyyy) What happened? *
Has anyone in your family or friends attempted or committed death by suicide? *
If so, who? *
Have you experienced any sensory hallucinations (auditory, visual or physical touch)? If yes, please describe those and the last time you've experienced those. *
Any delusional thoughts (paranoia, grandiosity, overly anxious thoughts, not grounded in reality)? If yes, please describe those and the last time you've experienced those.
 *
Any disorganized thinking and speech (racing thoughts, flight of ideas)? If yes, please describe those and the last time you've experienced those.
 *
Do you have any legal issues? Have you had any legal issues in the past like current divorce proceedings, custody battles, past incarcerations, probations, arrests, or convictions? Please describe those and the dates. *
How would you describe your support system or lack thereof? (people, places, activities/hobbies or things/objects) *
What are your strengths or positives? *
What are your weaknesses or things you can improve on? *
What are possible barriers to treatment? *
Are you not seeking patient care but are instead requesting clinical supervision hours for your Graduate Studies, Internship, Practicum or Post Graduate experience including Licensing? If so, please contact us immediately at tdntcounseling@tdntsocialservices.org for more information. *
I have either already received, reviewed and accepted or will receive, review and accept the consent forms, HIPAA confidentiality notices, practice policies and cancellation policy of this nonprofit program.  I authorize the release of any medical and insurance information necessary to process any claim, while maintaining confidentiality based on HIPAA regulations.  I understand that it is my responsibility to obtain a valid referral from my primary care physician, if a referral is required by my insurance plan. I understand that if I do not obtain or have a referral on file that I may be held financially responsible for services received. I further understand that I am responsible for services that are considered non-covered expenses by my insurer and that I may ask any questions that I have should I need more information. *
Required
Today's Date (m/d/yyyy) *
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Any Additional Comments, Suggestions, or Inquiries? Your availability to meet for your sessions? When you'd like to meet for your initial intake?
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