Client Counseling Intake Form Page 3
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4Family of Origin
Mother’s name: ____________________________
Father’s name: _____________________________
Mother’s age: _____________
Father’s age: ______________
Mother’s location: __________________________
Father’s location: ___________________________
Mother’s health: ____________________________
Father’s health: _____________________________
Mother’s profession: _________________________
Father’s profession: __________________________
Write 3 adjectives to describe your Mother:
(1) _________________________________
(2) _________________________________
(3) _________________________________
Write 3 adjectives to describe your Father:
(1) __________________________________
(2) _________________________________
(3) _________________________________
Siblings and ages: ______________________________________________________________
Lifestyle Choices
Have you or others ever thought your use of alcohol or drugs was a problem?
Alcohol ___ Yes ___ No
Smoking ___ Yes ___ No
Other drugs ___ Yes ___ No
Amount/type of alcohol per week: ________________________________________
Amount/type of other drug use per week: __________________________________
Amount of tobacco use per day: __________________________________________
Amount/type of caffeine use per day: ______________________________________
History of chemical dependency treatments? _______________
If yes, when and where?
______________________________________________________________________________
______________________________________________________________________________
Do you attend AA or other similar groups? _____________________________________
Are there any guns or weapons in the house?____________________________________
Any legal charges (if so, please specify)? ______________________________________
________________________________________________________________________
Sources of Stress
Please list the things/events/problems that are creating stress in your life at the present time
(including significant losses and changes in your life):
1. __________________________________ 4. ________________________________
2. __________________________________ 5. ________________________________
3. __________________________________ 6. ________________________________
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