Meredith Beck-Joslyn, Ph.D.
Licensed Psychologist
1207 Delaware Avenue Suite 207
716-332-6110
Adult Intake Form
First Name: __________________________Middle Initial: ________Last: ______________________________
Date of Birth: _____/_____/_____
Age: ______ Gender (please circle): Male
Female Transgender
Address:
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Street
City
State
Zip Code
Preferred Phone #: _____________________ Other Phone #: ________________________
Primary reason(s) for seeking services:
 Depressed Mood
 Eating Disorder
 Anger/Irritability
 Alcohol/Drug Abuse
 Anxiety/Fears/Worries
 Sleep problems
 Grief/Loss
 Relationship Concerns
Briefly explain what brings you into therapy at this time:
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Self Injury
Coping skills
Stress management
Other:____________________
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What have you tried that has been helpful in managing your concerns?
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Describe special areas of interest (e.g., reading, crafts, physical fitness, church activities, traveling, etc.)
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What are some talents or skills that you feel proud of?
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Family Information
Relationship
Mother
Name
Age
Living?
Y/N
Living with you?
Y/N
Father
Y/N
Y/N
Spouse
Y/N
Y/N
Children
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Significant others (e.g., brothers, sisters, grandparents, step-relatives, half-relatives. Please specify
relationship.)
Relationship
Name
Age
Living?
Living with you?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Marital Status (more than one answer may apply):
 Single
 Engaged
 Divorced
 Unmarried, living
 Legally married
 Widowed
together
 Separated
 Annulment
Total number of marriages ___________
Assessment of current relationship:
 Good
 Fair
 Poor
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Parental Information
 Parents legally married
 Mother remarried
o Number of times:
 Parents have ever been separated
 Father remarried
o
Number of times:
 Parents ever divorced
Special circumstances (e.g., raised by person other than parents, information about spouse/children not living
with you, etc.):
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Development
Are there special, unusual, or traumatic circumstances that affected your development? __Yes __No
If Yes, please describe:
Has there been history of child abuse? __Yes __No
If Yes, which type(s)?
 Sexual
 Physical
 Verbal
If Yes, the abuse was as a:
 Victim
 Perpetrator
Other childhood issues:
 Neglect
 Inadequate
 Nutrition
 Other (please specify):
Comments regarding childhood development:
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Social Relationships
Check how you generally get along with other people: (check all that apply)
 Affectionate
 Follower
 Aggressive
 Friendly
 Avoidant
 Leader
 Fight/argue often
 Outgoing
Sexual orientation: _______________________
 Shy/withdrawn
 Submissive
 Other (specify):
Comments: __________________________________
Sexual dysfunctions? __Yes __No
If Yes, describe:
Cultural/Ethnic
To which cultural or ethnic group, if any, do you belong?
 African-American/Black

 American Indian or Alaskan Native

 Asian American/Asian

 European American/White/Caucasian

Hispanic/Latino/a
Native Hawaiian or Pacific Islander
Multi-racial
Other (please specify):_______________
Are you experiencing any problems due to cultural or ethnic issues? __Yes __No
If Yes, describe:
Other cultural/ethnic information:
Spiritual/Religious
How important to you are spiritual matters?
 Not
 Little
 Moderate
 Much
Are you affiliated with a spiritual or religious group? __Yes __No
If Yes, describe:
Were you raised within a spiritual or religious group? __Yes __No
If Yes, describe:
Would you like your spiritual/religious beliefs incorporated into the counseling? __Yes __No
If Yes, describe:
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Legal
Current Status
Are you involved in any active cases (traffic, civil, criminal)? __Yes __No
If Yes, please describe and indicate the court and hearing/trial dates and charges:
Are you presently on probation or parole? __Yes __No
If Yes, please describe:
Past History
Traffic violations (Not parking tickets): __Yes __No
DWI, DUI, etc.: __Yes __No
Criminal involvement: Yes No Civil involvement: __Yes __No
If you responded Yes to any of the above, please fill in the following information.
Charges
Date
Where (city)
Results
Education
Currently enrolled in school? __Yes __No
High school grad/GED __Yes __No
Name of School
Degree
Graduated (year)
Major
Other training:
Special circumstances (e.g., learning disabilities, gifted):
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Employment
Begin with most recent job, list job history:
Employer
Dates
Currently:
 FT
 PT
 Temp
Title
Reason you left the
job
 Laid-off
 Disabled
 Retired
How often do
you miss work?
 Social Security
 Student
 Other (describe):
Military
Have you ever been, or are you currently, enlisted in any branch of the US military? __Yes __No
Did your military experiences include any traumatic or highly stressful experiences which continue to bother
you? (e.g., war, combat, injuries, death, natural disasters, foreign deployment, etc.). __Yes __No
Dates
Have you…
Purposely injured yourself without suicidal intent (e.g., cut, hit, burned, etc.)
Y/N
Seriously considered attempting suicide
Y/N
Made a suicide attempt
Y/N
Considered seriously injuring another person
Y/N
Intentionally caused serious injury to another person
Y/N
Had unwanted sexual contact(s) or experience(s)
Y/N
Experienced harassing, controlling, and/or abusive behavior from another person
(e.g., friend, family member, partner, or authority figure)
Y/N
Been hit, punched, slapped, kicked, or otherwise physically harmed by a person
(e.g., friend, family, partner, or authority figure) with cruel or malicious intent
Y/N
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Medical/Physical Health
 Scarlet Fever
 Arthritis
 Frequent urination
 Sinusitis
 Asthma
 Headaches
 Smallpox
 Bronchitis
 Hearing problems
 Stroke
 Bed wetting
 Hepatitis
 Sexual
 Cancer
 High blood pressure
 Tonsillitis
AIDS
Dizziness
Nose bleeds
Alcoholism
Drug abuse
Pneumonia
Abdominal pain
Epilepsy
Rheumatic Fever
Abortion
Ear infections
Sexually transmitted
diseases
Allergies
Eating problems
Sleeping disorders
Anemia
Fainting
Sore throat
Appendicitis
Fatigue
 Chest pain
 Kidney problems
 Tuberculosis
 Chronic pain
 Toothache
 Colds/Coughs
 Mononucleosis
 Thyroid problems
 Constipation
 Mumps
 Vision problems
 Chicken Pox
 Menstrual pain
 Vomiting
 Dental problems
 Miscarriages
 Whooping cough
 Diabetes
 Neurological
disorders
 Diarrhea
 Nausea
 Other (describe):
 Measles
Current prescribed
medications
Dose
Dates
Purpose
Side Effects
Current over the counter
medications
Dose
Dates
Purpose
Side Effects
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Are you allergic to any medications or drugs? __Yes __No
If Yes, describe:
Please check if there have been any recent changes in the following:
 Sleep patterns
 Physical activity level
 Eating patterns
 General disposition
 Behavior
 Weight
 Energy level
 Nervousness/tension
Date
Reason
Results
Last physical exam
Last doctor’s visit
Last dental exam
Most recent surgery
Other surgery
Upcoming surgery
Nutrition
Meal How often Typical foods eaten Typical amount eaten
Meal
How often
Breakfast
______/week
Lunch
______/week
Dinner
______/week
Snack
______/week
Typical foods eaten
Comments:
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Please check any of family physical or mental health issues that you are aware of:
 Depressed Mood
 Body Image/Eating Disorder
 Sleep Disorder
 Anxiety/Fears/Worries
 Alcohol Abuse
 Thyroid Disorder
 Psychosis
 Drug Abuse
 Premature Death
Chemical Use History
Method of
use and
amount
Frequency of
use
Age at first
use
Alcohol
Used in
last 48
hours
Y/N
Used in
last 30
days
Y/N
Barbiturates
Y/N
Y/N
Valium/Librium
Y/N
Y/N
Cocaine/Crack
Y/N
Y/N
Heroin/Opiates
Y/N
Y/N
Marijuana
Y/N
Y/N
PCP/LSD/Mescaline
Y/N
Y/N
Inhalants
Y/N
Y/N
Caffeine
Y/N
Y/N
Nicotine
Y/N
Y/N
Over the counter
Y/N
Y/N
Prescription drugs
Y/N
Y/N
Other drugs
Y/N
Y/N
Substance of preference
1.
3.
2.
4.
Age of last
use
Describe when and where you typically use substances:
How do you believe your substance use affects your life?
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Reason(s) for use:
 Addicted
 Socialization
 Build confidence
 Taste
 Escape
 Other (specify):
 Self-medication
Does/Has someone in your family present/past have/had a problem with drugs or alcohol? __Yes __No
If Yes, describe:
Have you had withdrawal symptoms when trying to stop using drugs or alcohol? __Yes __No
If Yes, describe:
Have you had adverse reactions or overdose to drugs or alcohol? (describe):
Have drugs or alcohol created a problem for your job? __Yes __No
If Yes, describe:
Counseling/Prior Treatment History
Yes
No
Past (dates)
Present (dates)
Overall
experience
Counseling/Psychiatric treatment
Suicidal thoughts/attempts
Drug/alcohol treatment
Hospitalizations
Involvement with self-help
groups (e.g., AA, Al-Anon,
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Information about family/significant others (past and present):
Yes
No
Past
(dates)
Present
(dates)
Name of person in
treatment
Counseling/Psychiatric treatment
Suicidal thoughts/attempts
Drug/alcohol treatment
Hospitalizations
Involvement with self-help
groups (e.g., AA, Al-Anon,
Please check behaviors and symptoms that occur to you more often than you would like them to take place:
 Aggression
 Sick often
 Disorientation
 Elevated mood
 Avoiding people
 Judgment errors
 Phobias/fears
 High blood pressure
 Trembling
 Alcohol dependence
 Sleeping problems
 Distractibility
 Fatigue
 Chest pain
 Loneliness
 Recurring thoughts
 Hopelessness
 Withdrawing
 Anger
 Speech problems
 Dizziness
 Gambling
 Cyber addiction
 Memory impairment
 Sexual addiction
 Impulsivity
 Worrying
 Antisocial behavior
 Suicidal thoughts
 Drug dependence
 Hallucinations
 Depression
 Mood shifts
 Sexual difficulties
 Irritability
 Other (specify):
 Anxiety
 Disorganized
thoughts
 Heart palpitations
Briefly describe anything else that you think is important for your counselor to know at this time.
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