CLINICAL NEUROSCIENCE COUNSELING, LLC
Deborah Smith, MEd, LMHC ; James T. Harden, MSW, LICSW; Patricia Woodbury, LMHC
ADULT INTAKE QUESTIONNAIRE
In order for us to be able to better serve you, please fill out the following questionnaire
to the best of your ability. We realize there may be information that you do not
remember or have access to. Please just do the best you can. Thank you!
PATIENT IDENTIFICATION:
Name:
1st Appt Date:
Birth Date:
Age:
Sex:
Religion:
Marital Status:
Race:
Children:
Address:
City:
State:
Zip:
Home Phone #
Work #
Email address:
Male
Female
Cell:
PURPOSE OF THE CONSULTATION:
(Please give a brief summary of the main concerns)
What do you hope to gain?
MEDICAL HISTORY:
Current medical problems/medications:
Past medical problems/medications:
Doctors/clinics seen regularly:
Any history of head trauma: (describe):
Prior medical hospitalizations (place, cause, date, outcome):
Client ID: __________ Name: ________________________________________________
Clinician Name:_________________________________________
Clinician Signature: ____________________________________________ Date: ______________
Allergies/drug intolerances (describe):
CURRENT LIFE STRESSES (include anything that is currently stressful for you: examples include
relationships, job, school, finances, children):
FAMILY HISTORY:
Family Structure (who do you currently live with, add other information as necessary):
Significant Developmental Events (include marriages, separation, divorces, deaths, traumatic events,
losses, abused, etc):
Current Marital or Relational Situation/Satisfaction:
History of Past Marriages:
Natural Mothers History: Name:
age:
Occupation:
School: Highest grade completed:
Learning Problems: (Specify):
Behavior Problems: (Specify):
Marriages:
Medical Problems:
Has mother or any of her blood relatives ever had any learning problems or psychiatric problems
including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric
hospitalizations? (specify)
Natural Father’s History: Name:
age:
Occupation:
303 Bradley Blvd Suite 206; Richland, WA 99352; (509) 946-9715; Fax (509) 946-9765
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Client ID: __________ Name: ________________________________________________
Clinician Name: ________________________________________
Clinician Signature: ____________________________________________ Date: ______________
School: Highest grade completed:
Learning Problems: (Specify):
Behavior Problems: (Specify):
Marriages:
Medical Problems:
Has father or any of his blood relatives ever had any learning problems or psychiatric problems
including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric
hospitalizations? (specify)
Your siblings (names, ages, problems, strengths, relationship to patient):
Your children (names, ages, problems, strengths)
EDUCATIONAL HISTORY
Last grade completed:
Last school attended:
Average grades received:
Any academic problems?
Learning strengths:
What would your teachers have said about you?
Employment History: (summarize jobs you’ve had, list most favorite and least favorite:
Any work-related problems?
What would your employers or supervisors have said about you?
303 Bradley Blvd Suite 206; Richland, WA 99352; (509) 946-9715; Fax (509) 946-9765
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Client ID: __________ Name: ________________________________________________
Clinician Name: ________________________________________
Clinician Signature: ____________________________________________ Date: ______________
Military History:
Yes
If Yes, please explain:
No
Any Legal Problems (past/present)?
Alcohol and Drug History: The two sections below are for current use (or within the last two
months) and anything over two months ago will go in the second box.
Current (within the last 2 months)
alcohol (hard liquor,
inhalants (glue,
hallucinating drugs
beer, wine)
gasoline, cleaning fluids (LSD, mescaline,
white out, sharpie, etc) mushrooms)
tabacco
sleeping pills
Prescription
medications not
prescribed
marijuana
steroids
Cough Syrup
hash
cocaine or crack
Other:
Past (more than 2 months ago)
alcohol (hard liquor,
inhalants (glue,
hallucinating drugs
beer, wine)
gasoline, cleaning fluids (LSD, mescaline,
white out, sharpie, etc) mushrooms)
tabacco
sleeping pills
Prescription
medications not
prescribed
marijuana
steroids
Cough Syrup
hash
cocaine or crack
Other:
opiates (heroin,
codeine, morphine or
other pain killers)
amphetamines,
crank, ice, meth
opiates (heroin,
codeine, morphine or
other pain killers)
amphetamines,
crank, ice, meth
Cultural/Ethnic Background:
Describe your relationships with friends:
Describe your childhood atmosphere:
Describe yourself:
303 Bradley Blvd Suite 206; Richland, WA 99352; (509) 946-9715; Fax (509) 946-9765
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Client ID: __________ Name: ________________________________________________
Clinician Name: ________________________________________
Clinician Signature: ____________________________________________ Date: ______________