Counseling Intake Form (Page 2 of 2) in pdf

Educational history: Last year of school completed: _____________________ (or GED)

College: 1 2 3 4 Degree:___________________________________ Other: ______________________________

Single______ Married_______ Separated______ Divorced_____ Remarried______ Widowed_____

Do you have children? _________ Yes _________ No

If yes, list names, ages, and whether they live in your home

_________________________________________________________________________________________________________

Has anyone in your family ever had counseling before? If so, for what?________________________

_________________________________________________________________________________________________________

Any history of drug/alcohol abuse for self, father, mother, siblings? _____ Yes _____ No

If yes, please describe _______________________________________________________________________________

Do you use alcohol or nonprescription drugs? _____Yes _____No

If yes, describe frequency and type_________________________________________________________________

List any major health problems for which you have received treatment for in the last 24

months:

_________________________________________________________________________________________________________

Primary Care Physician: ____________________________________________________________________________

Phone:____________________________________

Are you taking any prescription drugs at this time? _____Yes _____No

If yes, what type, for what purpose, and who prescribed?

_________________________________________________________________________________________________________

Counseling Intake Form Page 2