Resilience Counseling Adult - Clinical Intake Form
Please fill out this form to the best of your ability. Please answer all questions as honestly and briefly as possible. We will have time to discuss important issues more in depth in your initial appointment and throughout the counseling relationship. It is important for your counselor to know the honest answers so that we are able to address your concerns safely and helpfully. All of your answers will be confidential. If the question is not applicable to you, please write N/A. Please tell your counselor if you need extra assistance in completing this intake form.
Personal Information
Today's Date *
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Name *
Your answer
Social Security Number *
Your answer
Driver's License or State ID number and state issued? *
Your answer
How did you hear about this counseling center? *
Your answer
Are you able to self pay for counseling services? I do not accept insurance. *
What is your ethnicity, city and state of your birth. If you were not born in the United States, in what country were you born? *
Your answer
Gender *
Date of Birth *
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YYYY
What is your age? *
Your answer
What is your education level? *
Current Home Address (Where do you live?) *
Your answer
What is your email? *
Your answer
May your counselor email you to leave a message? *
Cell Phone Number (with area code) *
Your answer
May your counselor leave a voicemail or message on your cell phone? *
Home Phone Number (with area code) *
Your answer
May your counselor leave a message at your home number? *
Work Phone Number (with area code) *
Your answer
May your counselor leave a message at your work number? *
What is the best way to contact you? *
Required
Please list two emergency contact persons in case of an emergency? (Name, Relationship, Phone number, email) *
Your answer
Who is your Primary Care Physician? (Clinic, Name and Phone number) How long have you been a patient? *
Your answer
Who is your psychiatrist? (Clinic, Name and Phone number) How long have you been a patient? *
Your answer
What are your personal interests or hobbies? *
Your answer
Are you active in any community or social groups? *
Your answer
Are you currently religious or spiritual? If yes, please describe your personal beliefs and/or affiliation. *
Your answer
What is your current relationship status? *
Required
How satisfied are you with your current relationship status? *
Not Satisfied
Very Satisfied
Have you ever been convicted of a crime? If yes, please list the conviction(s) and when you were convicted? (Please include DWI or DUI if applicable) *
Your answer
Do you have any disabilities? If yes, please describe. *
Your answer
Are you currently living alone or with others? If with others, please list each person's: name, age, & relationship to you. *
Your answer
What is your current employment status? *
Required
Are you satisfied with your current employment status? *
Not Satisfied
Very Satisfied
If employed or a student, where are you employed and/or where do you attend school? (N/A if not applicable) *
Your answer
What is your current military status *
Currently, what problems or concerns would you like to address? *
Required
If you checked other, please describe. *
Your answer
How difficult has it been for you to deal with these concerns? *
Not Difficult
Extremely Difficult
What counseling goals would you like to work towards with your counselor? *
Your answer
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