New Individual Intake – Building Blocks Counseling

Personal Information

Client's Name*

First Last

Email*

Phone

Date*

Chief concern*

Please describe the main difficulty that has brought you here:

Medical History

Clinic/Doctor's Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Doctor Consent

If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be fully informed and we can coordinate treatment?

Yes
No

Medications

Please list all current prescription and over the counter medications and doses

Treatment/Medical History

Please list any past treatment for psychological, psychiatric, drug or alcohol treatment, or counseling services you have received with provider names, dates and locations. Please list all major illnesses, injuries, accidents, hospitalizations, allergies or medical conditions.

Lifestyle

Living Situation*

Please select all that apply

Alone
Friend
Parent
Spouse
Partner
Divorced
Widowed

Co-habitation details*

First names, ages, and relationship of those who live with you

Past Relationships

List any previous marriages or significant relationships.

Abuse History*

I was not abused in anyway
I was abused

Type*

Please choose all that apply

Select All
Physical
Emotional
Sexual
Neglect

Age*

Child
Adult

Chemical Use and Legal Issues

Chemical Use*

Please select all that apply

Select All
Felt the need to cut down on your drinking
Felt annoyed by criticism of you drinking
Felt guilty about your drinking
Ever taken a morning “eye-opener” drink
None of the above

Legal Issues

Please list any current or past legal issues you may have including arrests, lawsuits, etc

Additional Information

Please list any additional information that would help me understand your problems and provide appropriate treatment

Checklist of Concerns

Please check ALL that apply*

Comments

This field is for validation purposes and should be left unchanged.