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COUNSELING INTAKE FORM

Masantol High School


Note: This information is confidential.

Demographic Information:
Name: Date of Birth: Address: Home/Mobile Phone: Email: Occupation (if applicable): Year and Section: ER Contact Relationship: How were you referred? Emergency Contact Phone: If online, which website? Is it ok to leave a message for you at this number? Y / N Is it ok to email you? Y / N Date: Age:

Gender: M / F

Family Systems:
Father Mother Name: Age: Home Address: Cell No: Religion: Nationality Occupation: Work Address: Highest Education: School Attended: Marital Status of Parents: ___ Married ___Never Married ___Partnered ___Separated ___Divorced ___Widowed
Brothers and Sisters: (including client-ordinal position)

Name 1. 2. 3. 4. 5. 6. 7.

Age

Educational Attainment

Health and Social Information:


1. How is your physical health at present? Poor Unsatisfactory Satisfactory Good Very Good 2. Are you now under a doctors care? If yes, Name of Doctor 3. Reason for doctors care: 4. Are you taking any medication? If yes, what kind: 5. Have you ever been hospitalized for a physical illness? Describe: 6. Any recent major illness or surgeries? 7. Are you having problems with your sleep habits? ___Yes ___No If yes, check where applicable: ___Sleeping too little ___Sleeping too much ____Poor quality sleep ____Disturbing dreams Other__________ 8. How many times per week do you exercise? How long? 9. Are you having difficulty with appetite or eating habits? ___Yes ___No If yes, check where applicable: ___Eating less ___Eating more ___ Restricting Have you experienced significant weight change in the last 2 months? ___Yes ___No 10. Do you smoke? _____Do you take drugs? ____ If yes, what kind? 11. Do you drink? ____ How much? 12. Have you had suicidal thoughts recently? ___Frequently ___Sometimes ___Rarely ___Never Have you had them in the past? ___Frequently ___Sometimes ___Rarely ___Never 13. Are you currently in a romantic relationship? ___ No ___Yes On a scale on 1 to 10, how would you rate the quality of your current relationship? 14. In the last year, have you experienced any significant life changes or stressors:

Spiritual History:
Do you consider yourself to be religious? ___Yes ___No If yes what is your faith? If no, do you consider yourself to be spiritual? ___Yes ___No Religious upbringing: ________________________ Present Religious Group: Is this an important part of your life? _______ Why?

Emotional Status:
Are you currently experiencing strong emotions? _____ If yes, describe: _____________ Do you make decisions based on your emotions? _____ How well does that work for you? Did you have what you would consider to be childhood or other traumas? ___ If yes, describe: Have you been treated for emotional disturbances? ___ If yes, when? Have you had any thoughts of suicide? If so, when __________________ Do you have any thoughts now?

Behavior circle any of the following behaviors that apply to you:


Overeat Insomnia Withdrawal Suicidal attempts Vomiting Lack of motivation Cant keep a job Smoke Drink too much Take drugs Take too many risks Nervous tics Compulsions Odd behavior Eating problems

Work too hard Phobic avoidance

Procrastination Outbursts of temper

Sleep disturbance Loss of control

Crying Aggressive behavior

Impulsive reactions Concentration difficulties

Are there any specific behaviors, actions, habits that you would like to change?

Feelings circle any of the following feelings that apply to you:


Angry Conflicted Contented Energetic Guilty Restless Fearful Relaxed Unhappy Depressed Hopeful Tense Annoyed Regretful Excited Envious Happy Lonely Panicky Jealous Bored Anxious Helpless Others: Sad Hopeless Optimistic

Physical circle any of the following symptoms that apply to you:


Headaches Dry mouth Twitches Sexual disturbances Bowel disturbances Visual disturbances Stomach trouble Palpitations Chest pains Tremors Hear things Numbness Skin problems Fatigue Tension Unable to relax Excessive sweating Flushes Dizziness Burning or itchy skin Back pain Fainting spells Tingling Hearing problems Tics Muscle spasms Rapid heart beat Blackouts Watery eyes Dont like being touched

Present Situation:
Please state why you decided to come for counseling/therapy: What is the nature of your situation? What would you like to experience that is different from what you are experiencing now? How long has this been a problem for you? Please state what you would like to work in this therapy:

Personal Agreements
I understand that I may be asked to do certain homework exercises", such as reading, praying, changing behaviors, and otherwise acting in my own best interest. I understand that I am entirely responsible for my own actions and I will always make my own final decisions regarding counseling. I further understand that much of the work done will be to resolve issues and will depend on my honesty, and willingness to do the things I need to do to move forward even if it is painful and difficult. I understand that whatever I say in a session is strictly confidential and will not be released to anyone without my consent unless I am violating codes of abuse, harm to myself or others.

_______________________________________________ (clients signature and date)

Rachel Eddins, M.Ed., LPC | 1501 Crocker Street, Suite One, Houston, TX 77019 | P: 832-338-6863, F: 713-630-0821