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Intake and History Information

Identification & Contact Information

format: MM/DD/YYYY
Individual
Couples/Partners
Minor child (under 13)
Teen (13-19)
Family
Group

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

Referral

Presenting Concerns & History

Nervous
Shyness
Anger
My thoughts
Concentration
Unhappiness
Phobias
Anxiety
Loneliness
Lack of Ambition
Depression
Self-esteem
Self-control
Inferiority
Stress
Temper
Sleep issues
Nightmares
Friends
Relaxation
Energy level
Weight
Appetite
Under eating
Over eating
My appearance
Health issues
Stomach issues
Bowel issues
Headaches
Memory
Age
Grief
Marriage
Separation
Divorce
Infidelity
Sexual/intimacy issues
Parenting
Finances
Legal matters
Education
Career choice
Future
Fears
Decision making
Sexual abuse
Physical abuse
Suicide thoughts
None
Marriage problems
Change in marital status
Death of spouse/partner
Family problems (children, in-laws)
Loss of job
Change in career
None
Major illness or injury-self
Major illness/injury/death -family member
Financial problems
Legal problems
Move
Change in family members (marriage/divorce)

Health & Medical Information

Women only

Women and Men:

Spiritual/Religious Beliefs/Practices

Relationships

Single
Actively dating
Not dating
Committed Relationship
Committed long distance
Engaged
Married
Domestic partnership
Separated
Divorced
Widowed

If currenty in a relationship:

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

Parental History

Education/Work

Military

Chemical Use

Treatment History

Yes
No
Within the last month
Drug
Inpatient
Outpatient counseling
Psychological
Psychiatric
Alcohol treatment

Suicide/Self harm/Abuse issues

If yes, please complete below

Self Harm

No
Cutting
Burning
Hurting yourself in any way
Potentially dangerous behaviors
Compulsive gambling
Compulsive spending
Unsafe sex practices

Abuse

Emotional
Sexual
Yes
Physical

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

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