Confidential Client Intake Form (Page 2 of 3) in pdf

Confidential Client Intake Form Page 2

Please list your father, mother, sisters, brothers, stepfamily relations, or other family members who had a significant effect on

your life (either positive or negative). (Use the back of this sheet if necessary.)

Name

Sex

Age or yr. of death

Relationship to you

Describe him/her (e.g. angry, out-

going, supportive, controlling)

COUNSELING HISTORY

If you have had any previous counseling, psychiatric treatment, substance abuse treatment, or residential/in-patient care, please

list the names of the therapists or programs. (Use the back of this sheet if necessary.)

Therapist’s Name or Program

Major Issue

Dates

Has anyone in your family ever been treated or hospitalized for substance abuse, mental health issues, or psychiatric conditions?

Yes

If yes, please describe:

Have any of your family members or friends ever attempted or committed suicide?

Yes

If yes, who and when:

MEDICAL HISTORY

Please list any conditions, illnesses, treatments, or surgeries that might be relevant to your reason for seeking counseling:

Are you currently receiving any medical treatment?

Yes

No If yes, please describe:

Please list all current medications you are taking and the reasons for taking them. (List even if you seldom use, or take

only as needed.)

Name of medications

Dose

Reason for taking

Are you taking these medications according to the doctor’s recommendations?

Yes

If no, please explain:

Confidential Client Intake Form Page 2