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: _________________________________________________________________________________