Client Intake Form
Welcome! Please fill out the following information. IF YOU CHOOSE NOT TO ANSWER, PLEASE TYPE N/A.

**The contents of this message and any attachments may be confidential and protected by law under HIPAA, certain information about a person’s health or health care services is classified as Protected Health Information. The privacy rule protects all "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. If you are not the named/ intended recipient of this message, please forward a copy to julieann@centerforhealthychange.com and delete the message and its attachments from your computer. Thank you.**

Email *
Your answer
Would you like to be updated via email with periodic news about the Center for Healthy Change or special offerings?
First and Last Name *
Your answer
Age *
Your answer
Date of Birth *
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Address *
Street, City, State, Zip
Your answer
Social Security # *
Your answer
Credit Card Information *
VISA OR MASTERCARD ONLY** Please provide Credit Card information to reserve your intake appointment. If you have any questions or cannot provide one, please call 760-634-1704
Full Name on Credit Card *
Your answer
Credit Card # *
Your answer
Expiration Date *
Your answer
Security Code *
This number can be found either following the credit card number or in the back (3 digits)
Your answer
Address Associated with the Credit Card *
Street, City, State, Zip code
Your answer
Name of the person who referred you to counseling: *
Please fill out the “Release of Information”, in your email attachments, if you would like communication with that person
Your answer
Please select the relationship to referral source *
You will be seen by: *
Required
Preferred Contact Phone Number # *
Your answer
Is it ok to text appointment reminders? *
Required
Please include cell phone carrier for text reminders *
Your answer
Relationship Status *
Required
Number of people in your family of origin *
Your answer
Mother alive yes or no *
If deceased how old were you at time of their death? *
Your answer
Father alive yes or no *
If deceased how old were you at time of their death? *
Your answer
Number of sisters, ages, and names *
Your answer
Number of brothers, ages, and names *
Your answer
What Is your birth order? *
Were you adopted? *
Required
Where did you grow up? Country, State *
Your answer
What was your first language? Do family members speak more than one language? Yes or No *
Your answer
Number of Pregnancies *
Your answer
Number of children? *
Your answer
Sex of children? *
Your answer
Age of Children *
Your answer
Name of person to contact in case of an emergency? *
Your answer
What is the relationship? *
Your answer
What is the phone #? *
Your answer
Are you in counseling now? *
Would you like me to contact your counselor *
If so, what is the counselor name? *
Your answer
What is the counselors phone #? *
Your answer
Have you been in counseling before? *
If yes, what was it for? *
Your answer
What is the reason you are seeking counseling at this time? *
Your answer
Person Responsible for Payment *
Required
If other than yourself, please fill out the following information: *
Street, City, State, Zip
Your answer
Medical History *
Have you ever been treated for or diagnosed with any of the following conditions? When? (ADD, ADHD, LD, hypo or hyper thyroid, Tourettes, epilepsy, diabetes, head injury, falls, concussions, head trauma, seasonal affective disorder, allergies, heart disease, depression, bipolar disorder, panic disorder, other?)
Your answer
Do you have any medical conditions that you are being treated for at this time? If yes, please describe *
Your answer
Are you taking any medication for the any of the above conditions or other conditions? If so, what? *
Your answer
Any Addictions? *
Required
Family History *
Has ANYONE in your family ever been diagnosed and treated for or diagnosed with any of the following conditions? When? (ADD, ADHD, LD, hypo or hyper thyroid, Tourettes, epilepsy, diabetes, head injury, falls, concussions, head trauma, seasonal affective disorder, allergies, heart disease, depression, bipolar disorder, panic disorder, other?)
Your answer
Are all of your immediate family members still alive? If not, who is no longer living, and for how long? *
Your answer
Has anyone in your family ever had trouble with addictive or excessive behaviors? *
Required
If yes, please list relationship to you and type *
Your answer
Were your parents ever divorced? How old were you? *
Your answer
Academic History *
Highest Degree earned/date/area of study
Your answer
Vocational History *
Current employment:
Your answer
Sleep patterns (loss of sleep, sleeping a lot) *
Hours of sleep needed to feel rested?
Your answer
Nutritional Habits *
How would you assess your nutritional habits? (poor, fair, good, excellent) Are their any foods you crave? If so, sweet, sour, salty?
Your answer
How satisfied are you with your sexual relations? *
Extremely Unsatisfied
Extremely Satisfied
Do you have any sexual relationship concerns? *
Your answer
How hopeful are you that counseling can help you at this time? Please fill in circle the number that indicates from 1 being the lowest and 10 being the highest. *
Not Hopeful
Very Hopeful
Center for Healthy Change Policy Agreement
Following our policies help make the Center as safe, effective, and comfortable as possible for everyone. Please read and check that you understand each policy. Thank you!
24 Hour Cancellation Policy *
Required
Scent Sensitivity Policy *
Required
Substance Use Policy *
Required
Personal Agreements *
I understand that I may be asked to do certain “homework exercises” such as reading, changing behaviors, and otherwise acting in my own best interest. I understand that I am entirely responsible for my own actions and I will always make my own final decisions regarding counseling. 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. Please sign and date below.
Your answer
Today's Date
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