Identification & Contact Information

Type of counseling

Where to leave message if needed - (name & phone number):

In case of emergency information (required by State Board of Behavioral Examiners)

Referral

How did you find Pathways Counseling Services, PLLC?

If applicable, who suggested that you contact PCS?

Presenting Concerns & History

Please describe the main difficulty or reason you are coming in for counseling and why now?

Life circumstances - in the last 6 months - please mark all - 1

Life circumstances - in the last 6 months - please mark all - 2

Please rate your level of motivation to change (1-10)

Additional information you feel would be helpful for counselor:

Health & Medical Information

From whom or where do you receive medical care:

List current medications/vitamins:supplements taken:

Women only

Women and Men:

Spiritual/Religious Beliefs/Practices

Are you affiliated w/a religion/belief system/place of worship

What gets you through difficult periods in life?

Relationships

If currenty in a relationship:

If applicable, how long of relationship now?

Are there any issues with extended family members you want to share?

Please share any information about your living arrangement you feel important

With whom are you currently living? Or Extended family and friends that are significant

#1 - Use of alcohol/Drugs/Mental Illness/Other issues

#2 - Use of alcohol/Drugs/Mental Illness/Other issues

#3 - Use of alcohol/Drugs/Mental Illness/Other issues

#4 - Use of alcohol/Drugs/Mental Illness/Other issues

Other individuals in your household & relationship

Parental History

Education/Work

Military

Legal issues

List and describe any arrests.legal issues/including custody:

Chemical Use

Treatment History

Are you under the care of a behavior health professional?

Yes
No
Within the last month

Have you ever received

Drug
Inpatient
Outpatient counseling

Have you ever received:

Psychological
Psychiatric
Alcohol treatment

Suicide/Self harm/Abuse issues

If yes, please complete below

Additional instances (when,why,how and result)

Self Harm

Do you now or have you ever engaged in self harm?

If yes, please describe here. Include when you started, frequency, what you did, the last time you engaged in this behavior(s) and anything else you think is important to share

Abuse

Have you been a victim of abuse

Emotional
Sexual
Yes
Physical

If yes, please explain when and ongoing issues from it.

Medications - List information on any medications taken for psychiatric or emotional issues

Additional medications prescribed (detail as above)

Intake and History Information