Gretchen Sparacino, M.A., LPC
Confidential Intake Information
I. IDENTIFYING INFORMATION
Last Name
First Name
Local Address (number and street)
 Local Phone Number
City
 Cell Phone Number
MI
Preferred name (if different)
State
Zip
 Work Phone Number
 Email Address
 Check above box for number at which we can contact you or leave a message. We will not identify ourselves or state why we are calling.
Birth Date ( M/D/Y)
 Male
Marital Status:  Single
 Married
 Living
Age
 Female
Together
 Separated  Divorced
Widowed
Disability Type  None
 Physical
 Learning
(Optional)
 Behavioral  Hearing
 Visual
 Other
Contact in case of Emergency
Name :
Phone:
Relationship:
Name of Health Insurance Company
Other MD or therapist who is treating you:
Name:
Phone:
Profession:
II. Medical Information:
Do you have any medical problems?  No  Yes If yes please describe:
Are you currently taking prescribed, over-the-counter, or herbal medication?  No  Yes If yes, which ones?
Do you use alcohol/drugs now?  No  Yes If yes what kinds?
How much daily?
How much weekly?
Have you ever had previous psychological counseling?  No  Yes
If yes, when?
With whom?
For how long?
Have you ever been hospitalized for suicide attempt, drug or
alcohol problems, or an emotional/behavioral problem?
 Yes
 No
If yes, where?
For how long?
When?
III. SERVICES SOUGHT
Please briefly describe why you are seeking services:
As a result of therapy, what do you most want to accomplish, i.e., resolve, change, discover?
How did you find out about us?
 Referral:
 Friend
 Self
 Family
 Phone-book
 Other:
Please Sign and date:
Signature:
Date:
Continued on next page
I’M FEELING:
(Please check all that apply)
____ agitated
____ anxious
____ angry
____ confused
____ depressed
____ irritable
____ fearful
____ frustrated
____ guilty
____ hopeless
____ “hyper”
____ unhappy
____ lonely
____ numb
____ overwhelmed
____ sad
____ fatigued
I’M HAVING DIFFICULTY:
____ accepting my situation
(Please check all that apply)
____ concentrating
____ controlling my behavior
____ expressing myself clearly ____ making decisions
____ taking care of myself
____ resolving conflict
____ I’m crying a lot
____ controlling my temper
____ relaxing
____ trusting
____ I’m worrying a lot
____ I don’t have enough support (friends, family, etc.)
____ I have panic attacks or phobias
____ I spend too much time on the computer or Internet
____ I don’t feel well most of the time
I’M HAVING:
(Please check all that apply)
____ relationship concerns
____ family problems
____ concerns about my job or work situation
____ financial or economic problems
____ legal problems
____ educational problems
____ health problems or concerns (specify) _________________________________
____ sleep problems:
____difficulty falling asleep
____ recent change in my appetite
____ difficulty staying asleep
____ concerns about my weight or appearance
____ concerns about my sexuality or sexual functioning
____ concerns about my own drug or alcohol use
____ thoughts about harming myself
____ difficulty waking up
____ concerns about my memory or mental functioning
____ concerns about a family member’s drug or alcohol use
____ thoughts about hurting someone else
____ concerns for my safety
MY CURRENT CONCERNS ARE CAUSING ME:
____ mild distress
____ moderate distress
____ serious distress
____ severe distress
I HAVE: (Please check all that apply)
____ had a traumatic experience in my life
____ been arrested (when, for?) ________________________
____ had experience of abuse:
____ sexual
____ physical
____ emotional
OTHER INFORMATION THAT IS IMPORTANT:
_________________________________________________________________________________