Resilience Counseling Minor Client - 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. Guardians and Parents, please have your child answer these questions with you if possible. Please tell your counselor if you need extra assistance in completing this intake form.
Today's Date *
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Client's Name *
Your answer
Parent/Guardian's Personal Information
Parent/Guardian's Name(s) *
Your answer
Parent/Guardian's Social Security Number(s) *
Your answer
Parent/Guardian's Driver's License or State ID number(s) and state issued? *
Your answer
Are you able to self pay? I do not accept insurance. *
How did you hear about this counseling center? *
Your answer
If you would like me to begin the process of becoming a mental health provider with your insurance provider, please state your insurance company's name. *
Your answer
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
Parent/Guardian's Gender(s) *
Your answer
Date(s) of Birth *
MM
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DD
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YYYY
What is your age(s)? *
Your answer
What is your education level? *
Current Home Address (Where do you live?) *
Your answer
What is your email? *
Your answer
May your child's counselor email you to leave a message? *
Cell Phone Number (with area code) *
Your answer
May your child's counselor leave a voicemail or message on your cell phone? *
Home Phone Number (with area code) *
Your answer
May your child's counselor leave a message at your home number? *
Work Phone Number (with area code) *
Your answer
May your child's 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 child's Primary Care Physician? (Clinic, Name and Phone number) How long have you been a patient? *
Your answer
Who is your child's psychiatrist? (Clinic, Name and Phone number) How long have you been a patient? *
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 military status *
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
Who all lives in the home: 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
Currently, what problems or concerns would you like your child's counselor to address with your child? *
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
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