Confidential Client Intake Form

Today's Date *

Name *

First

Last

Email *

Birthdate *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Referral and Emergency Information

Referred By (if applicable)

May I thank them? (if applicable)

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Relationship Information

Relationship Status

Employment / Education Information

Employment Status

Occupation

Employer

Student Status

Full-Time
Part-Time
Non-Student

Current School Name

Highest Level of Education

Degree

Health Information

Please list any health issues, if applicable.

Date of Last Physical

Please list any medications & dosages, if applicable.

Additional Information

Have you had previous experience with counseling?

Yes
No

Please briefly describe your previous experience with counseling, if applicable.

What specific event(s) or experience(s) have led you to seek counseling now?

In the space below, tell me what you think is important for me to know about you.

What was the role of religion or spirituality in your upbringing and in your current life?

What do you hope to gain from counseling at this time?

Do you have a diagnosis from a doctor or other clinician?

Yes
No

Please list previous mental health diagnosis made by other clinicians:

Do you have any physical or learning disabilities I should know about?

Yes
No

Are you or have you ever struggled with addiction of any kind?

Yes
No

Have you ever felt suicidal?

Yes
No

If yes, when and under what circumstances?

Have you ever attempted suicide?

Yes
No

If yes, when and under what circumstances?

Is there any other information you feel would be helpful for me to know?

Confidential Client Intake Form

Referral and Emergency Information

Relationship Information

Employment / Education Information

Health Information

Additional Information

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