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Client Counseling Intake Form

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Client Intake Form

Rose Counseling

14451 Hwy. 7, Suite #2A

Minnetonka, MN 55345

612.386.4864

Client Name______________________________________ Date of Intake_________________

Complete Address______________________________________________________________

Home Phone_______________ Work Phone_______________ Cell ______________________

Date of Birth______________ Email Address_________________________________________

Name of Employer or School______________________________________________________

Spouse or Parent/Guardian:

Name____________________________ Work Phone______________ # of yrs. Married ______

Place of Employment__________________________________ Date of Birth_______________

Family Members (if children, please give ages) and/or significant others____________________

______________________________________________________________________________

Current Service Providers_________________________________________________________

______________________________________________________________________________

Please provide the following information about yourself or your child if you are a parent or

guardian. This information will help me better understand the problems you are having. The

information is confidential and will not be released to anyone without your permission.

Problems that you are having:

___ Depression

___ Parent-child conflict (self)

___ Suicidal thoughts

___ Parent-child conflict (spouse)

___ Suicidal actions

___ Marital/relationship problems

___ Anxiety/Fears/Worries

___ Remarried family problems

___ Panic attacks

___ Violence in the family

___ Anger/Temper problems

___ Communication problems

___ Alcohol/other drug abuse (self)

___ Verbal/Emotional abuse

___ Alcohol/other drug abuse (family)

___ Sexual problems

___ Job/School problems

___ Sexual abuse (past or current)

___ Financial concerns

___ Low self-esteem

___ Legal problems

___ Compulsive gambling

Client Counseling Intake Form

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