Brooke-Randolph, LLC Intake form
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Full name
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Date of birth
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Wedding Date
(if married or engaged)
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Address
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Phone number
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Permission to leave a message at this number?
Email
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Adoption connection
check all that apply
Reason for seeking services
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Goals for counseling
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Previous counseling experience - Where? With whom? How did it go?
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Concerns about counseling
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Any questions for the first session?
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How did you find me?
Health History and Habits
Primary Medical Provider/Family Doctor
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Address for PMP/doctor
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Phone for PMP/doctor
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When was your last exam?
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List any medical diagnoses
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Surgeries or hospitalizations, including psychiatric hospitalizations
please include dates and hospital name
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Current medications
include dose, frequency, and prescribing physician
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Alleriges
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Average hours of sleep per night
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Glasses of water per day
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Nutritional level of your diet
Caffeine per day
include if coffee, soda, tea, tablets, etc
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Tobacco use
type and frequency
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Alcoholic drinks per week
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Exercise
types, intensity, frequency per week
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History or current illegal drug use
including misuse of prescriptions
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