Counseling Intake Form - Linda Ray Center

Name *

First

Last

Select Appointment Date & Time

Date

Time

Address *

Address Line 1

City

State

Zip Code

Cell Phone *

Home Phone

Relationship Information

Relationship Status *

How Long

Name of significant other

Children Information

Referred by:

What are you struggling with at this time: *

CURRENT SYMPTOMS:

Please check all that apply.

Have you seen a therapist before?

Yes
No

How long ago?

Have you ever been hospitalized for inpatients psychiatric issues?

Yes
No

for what reason?

How long ago?

PHYSICAL HEALTH

DESCRIBE YOUR CURRENT PHYSICAL HEALTH:

Excellent
Good
Fair
Poor

Describe any current health problems:

Do you take any medications?

Yes
No

If yes, please list: If you have a copy of your meds you do not need to fill this out.

Do you smoke:

Yes
No

If yes, now much do you smoke?

Do you use drugs?

Yes
No

How often do you drink?

Do your drink:

Wine
Beer
Liquor

How often do you drink?

1-4 drinks weekly
7 + drinks weekly

Has anyone ever told you they thought your drinking was out of control?

Yes
No

Are you a recovering alcoholic/drug addict?

Yes
No

Has anyone in your family history ever had a problem with alcohol/drugs?

Yes
No

SUICIDE

Do you Currently have thoughts about hurt yourself or someone else?

Yes
No

If yes, do you have a plan?

Yes
No

Please describe:

Have you attempted suicide in the past?

Yes
No

Please describe:

ELDER MALTREATMENT

WITHIN THE LAST 6 MONTHS HAS ANYONE INFLICTED ON YOU:

Support

Do you have a support system?

Yes
No

Relationship Information

PHYSICAL HEALTH

SUICIDE

ELDER MALTREATMENT

Support

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