Adult Intake Form (Page 2 of 5) in pdf

Has anyone in the child’s family experienced the following:

□Mental health illness Type: ____________________________ Relationship to you: ____________

□Abuse or trauma

Type: _____________________________ Relationship to you: ____________

□Drug/alcohol abuse Type: _____________________________ Relationship to you: ____________

□Suicidal behaviors

Type: ______________________________ Relationship to you: ____________

Length of time in jail: _________________ Relationship to you: ____________

□Incarceration

Employment & Education Information:

Current Employment Status: _____________________ Employer: ______________________________

Position Title: _______________________________________________________________________________

Education Experience: ______________________________________________________________________

Current Concerns:

What concern brings you into counseling? ________________________________________________

_____________________________________________________________________________________________

When did these concerns begin? __________________________________________________________

_____________________________________________________________________________________________

Please describe significant events occurring at that time, or since then, which may relate

to the development of this concern: _______________________________________________________

_____________________________________________________________________________________________

Are you having difficulties or stress at your current job? __________________________________

_____________________________________________________________________________________________

Adult Intake Form Page 2