Intake Form Template printable pdf download

Intake Form Template

Intake Form

Name _______________________________________ Home Phone ____________________

Address _____________________________________ Work Phone ______________________

City ________________ Zip _______ Occupation/Employer __________________________

Your age ______

Date of Birth _____________

                                              

Please rate your general satisfactions with life a present (circle one)

Very dissatisfied 0 1 2 3 4 5 6 7 8 9 10 very satisfied

Please rate your level of satisfaction in present marriage/significant relationship

Very dissatisfied 0 1 2 3 4 5 6 7 8 9 10 very satisfied

Have you had prior experience in counseling? Yes ( ) No ( )

If yes, please describe with whom, when, how long, and for what: ________________________

______________________________________________________________________________

What are three significant problems you face currently?

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

Is there anything in particular that you want the therapist to know about your situation?

______________________________________________________________________________

Intake Form Template