Client Intake Assessment Form Step 1 of 3 33% InstagramThis field is for validation purposes and should be left unchanged.Name First Last Gender: Male Female Other: If other:Ethnicity:Age:Birth Date: Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell/Home Phone:Email: Referred by (if Any):Check all that best describes the patient: Student Unemployed Employed P/T Employed F/T Social/Living Situation:Marital Status: Never Married Domestic Partnership Married Separated/Divorced Widowed How long in this relationship?How long married?If divorced, how long?On a scale of 1-10, how would you rate your relationship?Please enter a number from 1 to 10.Living Situation: House Apartment Shelter Homeless Other: If Other:List who lives with you:Name:Age:Relationship to you (ex:mother/sister) Add RemoveEmployment History:Are you currently employed? Yes No Where employed:What is your current job?How long have you worked there?Do you enjoy your work? Yes No Is there anything stressful about your current work? Legal:Are you or parent considering filing for Disability? Yes No Are you or parent considering filing for Divorce/Separation? Yes No Are you or a member of your immediate family, currently in or have any pending legal court proceedings? Yes No If yes, briefly explain:Strengths and WeaknessesWhat do you consider to be some of your strengths?What do you consider to be some of your weaknesses?Faith:Do you consider yourself to be spiritual or religious? Yes No If yes, describe your faith or belief:Church attended: As a child Regularly Irregularly Seldom Medical:Date of last physical:Name of Physician:List all medications you are currently taking, what they are for and who prescribes them:Medication:Prescribed for:Doctor:How long: Add RemoveAre you compliant with your medications? No Yes N/A Symptoms: Check which best describes you: 0=None, 1=Mild, 2=Moderate, 3=Severe. Indicate duration (weeks/months/years)Acute Stress0123How long?Agitation0123How long?Anger/Rage0123How long?Anxiety0123How long?Appetite Disturbance0123How long?Concentration0123How long?Decreased Energy0123How long?Decreased Mood0123How long?Elevated Mood0123How long?Flashbacks0123How long?Grief0123How long?Helpless/Hopeless0123How long?Impulsive0123How long?Intrusive Thoughts0123How long?Irritability0123How long?Obsessive Compulsive0123How long?Occupational0123How long?Oppositional/Defiance0123How long?Panic Attacks0123How long?Psychosis0123How long?Relationships0123How long?Substance Abuse/Dependence0123How long?Sleep Disturbance0123How long?History and Previous Treatment:What significant life changes or stressful events have you experienced recently:What significant life changes or stressful events have you experienced over the last year:Have you attended counseling before? No Yes With Whom?When?Psychotropic - Within the last year? Yes No Prescribed by Psychiatrist/PCP? Yes No If yes, Type(s):Frequency:Quantity:Date of Last Use:Duration of Current Pattern:Pain Meds- Within the last year? Yes No Prescribed by Psychiatrist/PCP? Yes No If yes, Type(s):Frequency:Quantity:Date of Last Use:Duration of Current Pattern:Drug Use- Within the last year? Yes No If yes, Type(s):Frequency:Quantity:Date of Last Use:Duration of Current Pattern:Alcohol Use- Within the last year? Yes No If yes, Type(s):Frequency:Quantity:Date of Last Use:Duration of Current Pattern:Have you attended drug/alcohol counseling before? No Yes Have you been hospitalized for mental health, drug, alcohol or domestic violence problems? No Yes If yes, please explain when:If yes, please explain where:Family Mental Health History: In the section below identify if there is a family history of any of the following. If yes, please indicate the duration of the problem for that family member.Alcohol/Substance Abuse Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleAnxiety Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleDepression Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleDomestic Violence Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleEating Disorders Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleObesity Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleObsessive Compulsive Behavior Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleSchizophrenia Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleSuicide Attempts Yes No Please specify the duration of the problem for each member of your family.SelfSpouseChildMotherFatherBrother/SisterAunt UncleHave you experienced a traumatic event? (Check all that apply) Accidental Physical Injury Industrial Accident Work Accident Invasive Medical Procedures Injury or Illness Motor Vehicle Accident Natural Disaster Property Loss Death of a Loved One Injury or Illness of a Loved One Threat to a Loved One Witness to Violence Suicide of a Loved One Adult Sexual Assault Captivity Childhood Sexual Abuse Combat & Military Sexual Trauma Rejection (Scapegoating, Shunning) Cults and Entrapment Domestic Violence Physical Assault Rape Robbery Sexual Harassment Threat of Physical Violence Torture Victim of Crime Victim of Violence Witnessing Traumatic Event Client Signature:Your NameYour NameYour NameYour NameDate:
