Client Information

Please Complete Your Intake Information Prior To Your First Appointment.

Extra space provided for longer answers.

Today's date:

Referral Source:   

Telephone Book

Doctor

Other

Email:

Client's name:

Age:

Date of Birth:

Address:

City:

Home Phone:

Cell Phone:

Zip:

Occupation or school grade:

Work Phone:

Employer/school:

Highest level of education:

Marital Status:

If client is under the age of 18:

Father:

Address:

Employer:

Phone:

Mother:

Address:

Employer:

Phone:

Or legal guardian:

Name:

Address:

Employer:

Phone:

If you plan to use health insurance please provide the following:

Insurance Co.:

Member ID #:

Customer service phone number for benefits and eligibility:

Spouse's name:

Age:

Occupation:

Children's names/ages:

Others living at home:

Emergency contact:

Name:

Home phone:

Work phone:

Cell phone:

Primary physician:

Phone:

List any significant health problems:

List any medications/dosages
that you are presently taking:

Any previous counseling/therapy?

Yes

No

If yes, when?

Name of therapist:

Give brief description of issues worked on:

Reason for coming to counseling today:


Any history of the following?

Suicidal

Yes

No
Aggressive behavior

Yes

No
Substance abuse

Yes

No
Hospitalization

Yes

No
Head injury

Yes

No
Abuse

Yes

No
Do you smoke?

Yes

No
Do you attend religious services?

Yes

No
Do you have sleep disturbance?

Yes

No

Relevant family history (back to grandparents)

Mental health history:

Suicide:

Substance abuse:

Abuse:

Serious illness:

Separation from child or parent:

Social/relationship problems:


Your strengths
(knowledge, interests, skills, aptitudes, experiences, character):

Your response to stress:

Other significant information that you would like to add:

655 East Valley Road
Suite 200A
Basalt, CO 81621
Phone: (970) 963-5661
E-mail: cmac@sopris.net

Copyright © Adult & Adolescent Counseling Services, 2010. All Rights Reserved