New Solutions Counseling - Adult Intake Form
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Email *
Client Name (First, Middle Initial, Last) *
Address *
City, State, Zip *
Cell Number (Including Area Code) *
What number may we leave a confidential message? *
Required
Home Phone Number (Including Area Code) *
Emergency Contact: Name *
Emergency Contact: Relationship *
Emergency Contact: Phone Number *
May we contact this person in case of an emergency? *
Are you currently employed? *
Current Employer
Occupation
School or College Attending
Highest Level of Education Completed *
Degree Received
Medical History: Primary Care Physician *
Physician's Location *
Please list health problems including allergies *
Please list any hospitalizations (including dates/reasons) *
Please list all medications you are taking and the dosage/frequency of use below. *
Have you ever been treated for substance abuse? *
If so, please list providers and dates of treatment.
Please check how often you do the following: Smoke? *
Amount:
Please select how often you do the following: Drink Alcohol? *
Amount:
Please check how often you do the following: Use drugs? *
Amount:
Please state the reason you are seeking professional counseling services at this time. *
Please list your goals for counseling. *
Please identify symptoms that relate to the reason you are seeking counseling at this time. *
Required
Have you ever experienced anything you perceived as traumatic? If so, please describe. (Examples: robbery, rape, death in family, domestic violence, sexual abuse, emotional abuse, physical abuse, severe injury, combat) Trauma can be either witnessed or experienced. *
How would you rate the seriousness of your present situation in severity 1-10,  as you feel now? *
How would you rate the seriousness of your present situation in severity 1-10,  as you felt 6 months ago? *
How would you rate the seriousness of your present situation in severity 1-10,  as you felt one year ago? *
Have you ever been abused sexually, verbally, emotionally or physically? If so, please explain. *
Are you currently, or have you in the past, had thoughts of suicide or self-harm (cutting, burning, etc.)? If so, please explain. *
Prior Mental Health Counseling: If you have received prior counseling, please list your provider/therapist, the period of treatment and the previous diagnosis. *
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