Adult Client Intake Form
Background Information & Goals
Name*
Date Of Birth*
Age*
Home Address*
City*
Zip*
Cell Phone*
E-mail*
Occupation*
Emergency Contact Info.*
Primary Care Dr. Name*
Referred / Found By...*
Friend or Family
Professional
Online Directory
Internet Search
Google Maps
Relationship Status*
Married
Engagged
Committed Relationship
Dating
Single
Divorced
Widowed
Areas you want to address in counseling/coaching*
Feelings/Mood
Career/education
Family
Phase of life
Children/Parenting
Stress
Relationships
Assertiveness
Alcohol or Drug use
Health Problems
Abuse Issues
Childhood experiences
Spirituality
Loss or death
Self-esteem
Legal Issues
Which of the following apply ?*
Frequently sad or depressed
Overwhelming worries
Difficulty falling or staying asleep
Unable to concentrate
Irritable and/or short temper
Significant change in weight
Low energy level/fatigue
Feeling excessive guilt or shame
Unable to relax
Lack of appetite/increased appetite
Loss of interest in activities/hobbies
Feeling hopeless
Feeling worthless
Difficulty motivating
Withdrawn/isolating self
Cry easily/often
Difficulty making a decision
Difficulty finishing tasks
Difficulty with Friends/Family
Thoughts to hurt self or others
Physical Pain
Feeling restless or keyed up
Restless unsatisfying sleep
Muscle tension
Panic Attacks
Mood Swings
Decreased need for sleep
Feel more talkative than usual
Excessive spending/shopping
Excessive gambling
Relationship Problems
Intimacy Issues
Substance Abuse
Risky behaviors
Troubling thoughts about past
Nightmares
Startle easily
Too neat and orderly
Repeating certain behaviors
Painful Memories
Easily upset or angered
Feeling different from people
Shy around others
Increasingly forgetful
Strong fears
Difficulty with work or school
Names / Ages of any Children
What motivated you to look for a counselor/coach?*
What do you wish to change/achieve from therapy?*
Ever been to counseling? If so, how was it?*
What are your strengths?*
Which of the these apply?*
Being Treated For A Medical Issue
Currently Taking Medication
Exercise Regularly
Drink Too Much Caffeine
Drink Too Much Alcohol
Use Tobacco Products
Use Recreational Substances
Hospitalized For Mental Illness
Family History Of Mental Illness
Family Hx Of Substance Issues
Pretty Much In Good Health
Have A Good Support System
Spiritual Or Religious Practice
Enjoy Activities Or Hobbies
Please elaborate on these wellness items ...
Have you experienced ...?*
Traumatic Event
Domestic Violence
Verbal Abuse
Physical Abuse
Sexual Abuse
Legal Problems
Significant Loss
Dysfunctional Family As Child
Please elaborate on these experiences...
Is there anything else you would like to add?