Catholic Counseling Service

CLIENT INTAKE FORMClient Contact Information Date of First Session _______________

Name: ___________________________________ Email Address: ___________________________________

Cell Phone: ________________________________ Alternative Phone: ________________________________

Home Address: _____________________________________________________________________________

Emergency ContactName: _____________________________ Relationship: __________________Phone: _________________

Address: __________________________________________________________________________________

Client InformationHow did you hear about Catholic Counseling Service: ______________________________________________

Date of Birth: ______________________________ Employment: ____________________________________

Check the highest level of schooling that you have completed:

□ Elementary School □ High School □ College □ Post College □ Trade School □ GED □ Other ___________

Have you served in the military: □ Yes □ No

If yes, what branch: ______________________________ How many years of service: ___________________

Briefly describe your work history:______________________________________________________________

__________________________________________________________________________________________

Have you ever been in trouble with the law: □ Yes □ No

If yes, please explain: ________________________________________________________________________

Are you currently involved in legal problems: □ Yes □ No

If yes: □ Divorce/Separation □ Custody □ Lawsuit □ Parole □ Probation □ Other: _______________

Have you been a victim or perpetrator of abuse: □ Yes □ No

If victim: □ Sexual □ Emotional □ Physical

If perpetrator: □ Sexual □ Emotional □ Physical

1

This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.

Catholic Counseling Service

Current Family & Family of Origin History

Marital Status: □ Single □ Committed relationship □ Married □ Separated □ Divorced □ Widowed

How many year(s) have you been in your current marriage or relationship: _____________

Were you previously married: □Yes □ No If yes, how many times: ________________

Was your spouse/partner previously married: □Yes □ No If yes, how many times: ________________

Are you currently sexually active: □ Yes □ No

Do you have trouble in your relationships with others: □ Yes □ No

Please list your children’s name(s), age(s), and occupation(s) including “student”:

Name Age Occupation

__________________________ ________ ________________________________________________ ________ ________________________________________________ ________ ________________________________________________ ________ ______________________

Please list additional person(s) living with you:

Name Age Relationship Occupation

__________________________ ________ ______________________ __________________________________________________ ________ ______________________ __________________________________________________ ________ ______________________ __________________________________________________ ________ ______________________ ________________________

Please list below any physical or emotional health problems that members of your family are currently suffering or suffered in the past—Include relevant extended family such as parents: ____________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Is there a family history of mental illness, attention problems, or addiction? □ Yes □ No

If yes, please explain: ________________________________________________________________________

Medical History2

This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.

Catholic Counseling Service

Are you currently under treatment by a psychiatrist: □ Yes □ No

If yes, Psychiatrist’s Name: ________________________ Psychiatrist’s Phone Number: ___________________Would you sign a release of information to coordinate care with them: □ Yes □ No

Have you ever been diagnosed with a mental disorder: □ Yes □ No If yes, please list any and all diagnoses: _________________________________________________________

When was your last physical exam: ________________

Physician’s Name: ______________________________ Physician’s Phone Number: ______________________ Would you sign a release of information to coordinate care with them: □ Yes □ No

Please list medications below.

Medication Dose/Frequency Length of Time Condition Being Treated

__________________________ __________________ ___________ ____________________________

__________________________ __________________ ___________ ____________________________

__________________________ __________________ ___________ ____________________________

__________________________ __________________ ___________ ____________________________

Please indicate any substances that are recreationally used—outside of a prescribed medication: Type When How Often□ Alcohol □ Past □ Present □ Daily □ Weekly □ Monthly□ Prescription Drugs □ Past □ Present □ Daily □ Weekly □ Monthly□ Marijuana □ Past □ Present □ Daily □ Weekly □ Monthly□ Heroin □ Past □ Present □ Daily □ Weekly □ Monthly□ Cocaine □ Past □ Present □ Daily □ Weekly □ Monthly□ Hallucinogens □ Past □ Present □ Daily □ Weekly □ Monthly□ Other: _______________ □ Past □ Present □ Daily □ Weekly □ Monthly

List your health conditions or illnesses: Note approximate date or age of the onset for each condition/illness.

Health Condition or Illness Age or Date

_______________________________________________________ _________________________________

_______________________________________________________ _________________________________

_______________________________________________________ _________________________________

Reason for CounselingHave you at any point past or present engaged in counseling: □ Yes □ No

3

This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.

Catholic Counseling Service

If yes: □ Psychiatrist □ Psychologist □ Social Worker □ Minister □ Counselor □ Other

What led you to end counseling or therapy: ______________________________________________________

In the best way you can, please explain your reason for choosing to begin counseling at this time.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Presenting Problems and ConcernsPlease identify your current symptoms.

□ Addictions

□ Anger/Temper Problems

□ Anxiety

□ Behavior Problems

□ Crying

□ Cutting/Hurting Yourself

□ Depression

□ Eating Problems

□ Fears

□ Financial Problems

□ Hearing Voices/Seeing Things

□ Homicidal Thoughts

□ Inability to Focus/Concentrate

□ Not Accomplishing Work/Tasks

□ Obsessive-Compulsive Behaviors

□ Pornography Problems

□ Parenting Stress

□ Panic Attacks

□ Relationship Problems

□ Sexual Problems

□ Sexual Compulsions

□ Sleep Problems

□ Suicide Attempts

□ Suicidal Thoughts

If your symptom is not listed, please describe:

__________________________________________________________________________________________

__________________________________________________________________________________________

Briefly describe the role religion and spirituality play in your life:

__________________________________________________________________________________________

__________________________________________________________________________________________

4

This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.