TODAY’S DATE_________________________
INTAKE FORM
Please provide the following information and answer the questions below.
Please note: information you provide here is protected as confidential information.
Client Name: ______________________________________________________________
(Last)
(First)
(Middle Initial)
Address: ________________________________________________________________
(Street and Number)
________________________________________________________________________
(City)
(State)
(Zip)
Home Phone: _________________________
May we leave a message? □ Yes □ No
Cell/Other Phone: _______________________ May we leave a message? □ Yes □ No
E-mail: _________________________________________ May we email you? □ Yes □ No
*Please note: Email correspondence is not considered to be a confidential medium of communication.
SS# ____________ - __________ - ____________
Birth Date: ______ /______ /______ Age: ________
Gender: □ Male □ Female
IF UNDER 18 YEARS, Name of parent/guardian
_______________________________________________________________
(Last)
(First)
(Middle Initial)
Client Ethnicity: □ White/Caucasian □ Asian or Pacific Islander □ Hispanic □ African American (not of
Hispanic origin) □ Native American or Alaskan Native
This information will be used for classification purposes only.
Client Marital Status: □ Never Married
□ Separated
□ Domestic Partnership
□ Divorced
□ Married
□ Widowed
Parent Marital Status (if under 18): □ Never Married □ Domestic Partnership
□ Separated
□ Divorced
□ Married
□ Widowed
Please list first names of client’s children, and their age(s):
___________________________________________________________________________
Referred by (if any): _______________________________________________________
Revised 1/15/2015
EMERGENCY CONTACT INFORMATION
NAME:_____________________________________________________________
RELATIONSHIP: _____________________________________________________
LOCAL PHONE NUMBER______________________________________________
PERMISSION TO CALL Client Signature:_________________________________
Have you previously received any type of mental health services (psychotherapy, psychiatric
services, etc.)?
□ No
□ Yes
Previous therapist/practitioner: _________________________________________
Are you currently taking any prescription medication?
□ Yes
□ No
Please list: _______________________________________________________________
________________________________________________________________________
Have you ever been prescribed psychiatric medication (e.g., antidepressant, anti-anxiety)?
□ Yes
□ No
Please list medications and provide dates: ___________________________________________
_____________________________________________________________________________
Are you a veteran of the U.S. Armed Forces?
□ No
□ Yes
If yes, in which branch did you serve? __________________________________________
Did you serve in combat?
□ No
□Yes
GENERAL HEALTH INFORMATION
1. How would you rate your current physical health? (please circle)
Poor
Unsatisfactory
Satisfactory
Good
Very good
Please list any specific health problems you are currently experiencing:
________________________________________________________________________
2. How would you rate your current sleeping habits? (please circle)
Poor
Unsatisfactory
Satisfactory
Good
Very good
Please list any specific sleep problems you are currently experiencing:
________________________________________________________________________
3. Date of last medical exam: ____________
Phone: ________________
Family doctor: ______________
Address: ____________________________________
4. Do you currently have, or have you ever had any of the following health problems?
High blood pressure
Heart disease
Stroke
Diabetes
Cancer
Asthma
Head Injuries
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Kidney Disease
Jaundice of liver
Anemia
Thyroid/endocrine
STD
Ulcer/gastritis
Epilepsy/seizure
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
5.How many times per week do you generally exercise? __________
What types of exercise to you participate in? ____________________________________
________________________________________________________________________
6. Please list any difficulties you experience with your appetite or eating patterns:
________________________________________________________________________
7. Are you currently experiencing overwhelming sadness, grief, or depression?
□ No
□ Yes
If yes, for approximately how long? ___________________________________________
8. Are you currently experiencing anxiety, panic attacks, or have any phobias?
□ No
□ Yes
If yes, when did you begin experiencing this? ___________________________________
9. Are you currently experiencing any chronic pain?
□ No
□ Yes
If yes, please describe: _____________________________________________________
10. Do you drink alcohol more than once a week?
□ No
□ Yes
11. How often do you engage recreational drug use?
□ Daily
□ Weekly
□ Monthly
□ Infrequently
12. Are you currently in a romantic relationship?
□ No
□ Never
□ Yes
If yes, for how long? __________________
On a scale of 1-10, how would you rate your relationship? __________
13. What significant life changes or stressful events have you experienced recently:
______________________________________________________________________
______________________________________________________________________
14. Are you considering suicide?
□No
□Yes
15. Have you ever made an attempt to commit suicide?
16. Do you have a plan to commit suicide? □No
□Yes
17. Have you had any legal issues in the past?
□No
□No
□Yes
□Yes
If yes, please explain: ____________________________________________________
_______________________________________________________________________
18. Have you experienced any situations of abuse (physical, psychological, sexual)?
□ No
□ Yes
If yes, please explain: ______________________________________________________
________________________________________________________________________
FAMILY MENTAL HEALTH HISTORY
In the section below, identify if there is a family history of any of the following. If yes,
please indicate the family member’s relationship to you in the space provided (father,
grandmother, uncle, etc.).
____________________________________________________________________________________
Please Circle
List Family Member
Alcohol/Substance Abuse
yes/no
_______________________
Anxiety
yes/no
_______________________
Depression
yes/no
_______________________
Domestic Violence
yes/no
_______________________
Eating Disorders
yes/no
_______________________
Obesity
yes/no
_______________________
Obsessive Compulsive Behavior
yes/no
_______________________
Schizophrenia
yes/no
_______________________
Suicide Attempts
yes/no
_______________________
ADDITIONAL INFORMATION
1. Are you currently employed?
□ No
□ Yes
Currently a student?
□ No
□ Yes
If yes, what is your current employment situation, and/or school name?
________________________________________________________________________
Do you enjoy your work? Is there anything stressful about your current work?
________________________________________________________________________
________________________________________________________________________
2. Do you consider yourself to be spiritual or religious? □ No
□ Yes
If yes, describe your faith or belief:
________________________________________________________________________
3. What do you consider to be some of your strengths?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. What do you consider to be some of your weaknesses?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5. How and with whom do you spend leisure time?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. What would you like to accomplish out of your time in therapy?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________________
Annual Household Income
 Up to $15,000
 $15,001 to $30,000
 $30,001 to $40,000
 $40,001 to $50,000
 Over $50,000
Do you have medical insurance?
 Yes
 No
If Yes, Provider: ________________________________
Fees
Intakes
$50
Clinical Counseling, session rate
$100 *
Sliding Fee Scale is available for qualifying applicants.
Drug & Alcohol Evaluation
Anger Management Evaluation
Anger Management (10 sessions)
$150
$150
$1,000
Request for Records
$25
Regular therapy services: Sessions are 50 minutes.
Credit cards are accepted – however, Daemion Counseling Center incurs a processing fee
of 2.75% (of total transaction) for swiping a card, or 3.5% + $.15 (for manual entry) for these
transactions that will be added to your payment.
All of your responses are confidential and we never rent or sell your information.
FOR OFFICE USE ONLY:
Client #: ____________
Classification: _________________________
Assigned Fee: _________________
Counselor Assignment: __________________
Date entered into computer: ___________________