Adult Intake Form (Page 4 of 5) in pdf

Please check any physical symptoms that apply to you:

□Hearing things

□Stomach trouble

□Blackouts

□Don’t like being touched

□Nightmares

□Tension

□Fainting spells

□Rapid heart beat

□Tics

□Seeing things

□Fatigue

□Tremors

□Sexual disturbances

□Unable to relax

□Headaches

□Other: ____________________

Other concerns or difficulties you have: ___________________________________________________

_____________________________________________________________________________________________

Goals for counseling: ______________________________________________________________________

_____________________________________________________________________________________________

Have you attended counseling before? □ Yes □ No Dates: _______________________________

Reasons for previous counseling: __________________________________________________________

_____________________________________________________________________________________________

Do you have a previous mental health diagnosis? _________________________________________

_____________________________________________________________________________________________

Have you had any significant losses? (death, job loss, pet lot, miscarriage etc.) ___________

_____________________________________________________________________________________________

Have you ever been abused or experienced any trauma? _________________________________

_____________________________________________________________________________________________

Adult Intake Form Page 4