expectgreathingscounseling@gmail.com – 425-757-0874
Intake
Please complete all information on this form and bring it to your first counseling session
Demographics:
Today’s Date ___________________
Name _____________________________________________________
Date of Birth ____________
Home Phone ___________________
May I leave messages on this phone? ( ) y ( ) n
Work Phone ___________________
May I leave messages on this phone? ( ) y ( ) n
Cell Phone _____________________ Email ______________________________________________
Address ____________________________________________________________________________
City _______________________________________
Zip Code ____________________________
Emergency Contact ___________________________________ Relationship to You _________________ Phone _________________________
Sexual Orientation ( ) Heterosexual ( ) Homosexual ( ) Bisexual ( ) Other ( ) Prefer not to answer
What gender do you identify with? ( ) Male ( ) Female ( ) Other
Who referred you? (if applicable) ________________________
Relationship Status:
Are you: Single ( ) Dating ( ) Married/Partnered ( ) Divorced/Separated ( ) Widowed ( )
If applicable, describe your relationship with your current partner (place an “X” on the line below.) Major Problems ( ) Minor Problems ( ) Satisfactory ( ) Very Satisfactory ( )
How long have you been in the relationship? __________________________________________________
Have you had any prior marriages? ( ) y ( ) n If so, how many? __________________________________
For how long were you married? __________________________________________________________
Children Please list any children you have and Indicate if they live with you part time, full-time or not at all: Name ____________________________________________________ Age _______
Do they live this you? ____________ P/T _______ F/T _______ Not at all _________
Name ____________________________________________________ Age _______
Do they live this you? ____________ P/T _______ F/T _______ Not at all _________
Name ____________________________________________________ Age _______
Do they live this you? ____________ P/T _______ F/T _______ Not at all _________
Name ____________________________________________________ Age _______
Do they live this you? ____________ P/T _______ F/T _______ Not at all _________
Name ____________________________________________________ Age _______
Do they live this you? ____________ P/T _______ F/T _______ Not at all _________
Name ____________________________________________________ Age _______
Do they live this you? ____________ P/T _______ F/T _______ Not at all _________
Educational/Occupational/Legal History:
What is your highest educational level attained? __________________________
Did you attend college? ( ) y ( ) n If so, what was your major? ___________________________________
Are you currently: ( ) working ( ) not working
What is your occupation? _______________________________________________________________
Do you have any pending legal issues? ( ) y ( ) n
Therapy Needs
List the top 3 problems for which you wish to be seen and/or would like to work on:
1. _________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
In the past, what has been helpful to you in dealing with these problems? ___________________________________________________________________________________ ___________________________________________________________________________________
What are your goals for treatment? ___________________________________________________________________________________ ___________________________________________________________________________________
Therapeutic History Have you ever been given a mental health diagnosis in the past from a mental health professional? ( ) y ( ) n If so, what was the diagnosis? __________________________________________________
Have you ever had counseling before? If so, when and with whom? ___________________________________________________________________________________
Was it helpful?_____________________________________________
Are you currently taking psychiatric medication? ( ) y ( ) n If yes, please list: ___________________________________________________________________________________ ___________________________________________________________________________________
Have you taken psychiatric medication in the past? ? ( ) y ( ) n If yes, please list: ___________________________________________________________________________________
Have you ever attempted suicide in the past? ( ) y ( ) n If so, when? ______________________________
Are you currently suicidal? ( ) y ( ) n If so, do you have a plan? ___________________________________
Medical History:
Are you currently under treatment for any medical condition? ( ) y ( ) n If so, please list: ___________________________________________________________________________________ ___________________________________________________________________________________
Are you taking medication for this? If so, what? ___________________________________________________________________________________
Symptoms:
What symptoms contributed to you coming in today? (Check all that apply)
Appetite ( ) overeating ( ) voluntary vomiting ( )
binge eating ( ) weight gain ( ) weight loss ( )
recent appetite changes ( )
Sleeping & Energy ( ) difficulty falling asleep ( ) difficulty getting up ( )
Excessive energy ( ) difficulty staying asleep ( ) nightmares ( ) fatigue/loss of energy ( )
sleeping too much ( ) decreased need for sleep ( ) cannot quiet mind Relationships ( )
trust issues ( ) family issues ( ) parenting/step parenting concerns ( )
communication issues ( ) conflict/fighting ( ) boundary issues ( )
infidelity ( ) codependency ( ) controlling behavior ( )
role expectations ( ) abusive relationship ( ) anger issues ( )
emotional intimacy concerns ( ) sexual intimacy concerns ( ) low self esteem/insecurity ( )
obsessing about relationship ( ) dependency issues ( ) difficulty saying “no” ( )
Mood ( ) depression ( ) feelings of guilt ( ) panic attacks ( )
mania ( ) feeling numb ( ) hopelessness ( )
mood changes ( ) irritability ( ) helplessness ( )
anxiety ( ) fear ( ) sadness ( )
Behavior ( ) avoidance ( ) fear of objects/situations ( ) increased isolation ( )
compulsive behavior ( ) repetitive behaviors ( ) impulsive behavior ( )
difficulty staying on task ( ) loss of interest in activities ( )
Manipulation ( ) self harming behavior ( ) aggressive behavior ( ) using alcohol/drugs ( )
Cognition ( ) thoughts of self-harm ( ) racing thoughts ( ) frequent worries ( )
thoughts of harming others ( ) persistent disturbing thoughts ( ) critical thoughts of self ( )
obsessing ( ) hyper vigilance ( ) intrusive memories ( )
flashbacks ( ) feeling detached from self ( ) odd thoughts/behaviors ( )
questioning what is real ( ) hearing voices ( ) memory issues ( )
large gaps in memory ( ) difficulty problem solving ( ) difficulty concentrating ( )
Other ( ) concerns about sexuality ( ) past trauma ( ) current trauma ( )
sexual abuse ( ) problems with school ( ) problems with work ( )
housing problems ( ) financial difficulties ( )
Self Care/Social Assessment Do you exercise? ( ) y ( ) n
Frequency? __________________________________________________
How many meals per day do you eat? _______________
Average hours of sleep per night: __________________
What hobbies or leisure activities do you do ? (if any) ___________________________________________ ___________________________________________________________________________________
Do you spend time with friends or a community? ______________________________________________
Who do you count on for support? ________________________________________________________ ___________________________________________________________________________________
What brings you comfort? _______________________________________________________________
What are your strengths? _______________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Addiction Issues: Have you ever been treated for alcohol or drug use/abuse? ( ) y ( ) n If yes, where were and when? __________________________________________________________________________________
Do you think you may have a problem with alcohol or drug use? ( ) y ( ) n
How many alcoholic drinks do you consume each week? ________________________________________
In the past three months, what is the largest number of alcoholic drinks you consumed in one day? _________
Have you ever felt you ought to cut down on your drinking or drug use? ( ) y ( ) n
Have people ever told you that you should cut down on your drinking or drug use? ( ) y ( ) n
Have you ever felt bad or guilty about your drinking or drug use? ( ) y ( ) n
Do you currently use marijuana? ( ) y ( ) n If so, how often? ________________________________________________________________
Do you use other non-prescription drugs? ( ) y ( ) n If so, what? _________________________________
Do you view porn? ( ) y ( ) n If so, what is the frequency? _____________________________________
Outside of work, how many hours per day do you spend in front of a screen? _________________________
Other addiction issues- check all that may apply either now or in the past: Gambling ( ) y ( ) n Work ( ) y ( ) n Pornography ( ) y ( ) n Food ( ) y ( ) n Prescription pills ( ) y ( ) n Social Media ( ) y ( ) n Video games ( ) y ( ) n Sex/Relationship addiction ( ) y ( ) n Online Hook-ups ( ) y ( ) n Other _________________________________________
Spiritual Assessment:
Do you have a belief in God or a Higher Power? ( ) y ( ) n
Are you affiliated with a religion or spiritual group? ( ) y ( ) n Which one? _________________________
Do you attend regularly ( ) y ( ) n Is this a positive experience for you? __________________________
Do you have any spiritual concerns you would like to explore in therapy? ( ) y ( ) n If so, what are they? __________________________________________________________________ _________________________________________________________________________________
Do you want prayer to be part of your therapy process? ( ) y ( ) n ( ) undecide