Adult Intake

PERSONAL INFORMATION

Name*

Email Address*

Gender Male Female

Height

Weight

SS#

Age

Date of Birth

Address

City

State

Zip

Home Phone*

Business Phone

Cell Phone*

EMERGENCY INFORMATION

Name

Relionship to you

Home Phone

Business Phone

Cell Phone

EMPLOYMENT INFORMATION

Employer

Occupation/Title

Employer Information Address

City

State

Zip

Employer Information Phone

Hours per week

Years at job

EDUCATION

Highest level of education completed Some High School
Some College
Graduate School
High School Graduate/GED
College Graduate

Degrees held

CULTURAL/RELIGIOUS INFORMATION

Race Caucasian
African-American
Hispanic
Native American
Asian

Other

Cultural heritage

Do you regularly attend a church, synagogue or other religious institution? Yes No

Member? Yes No

Name of church/institution

Name of pastor

RELATIONAL INFORMATION

Marital status Single
Engaged
Married
Divorced
Widowed
Separated

If engaged, married, divorced or widowed, how long have you been so?

Number of previous marriages for you?

For your current spouse?

Name of spouse

Spouse’s age

Spouse’s Occupation

Description of your spouse's characteristics

CHILDREN INFORMATION

Please list your children, including step, adopted and foster children

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

FAMILY OF ORIGIN

Please list your mother, father, brothers, sisters, stepfamily and/or relatives who had a significant effect upon your life (positive or negative).

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

Please identify any of the following you experienced in your family: Physical Abuse
Emotional Abuse
Sexual Abuse
Abortions
Gambling
Drug/Alcohol Addiction
Religious Upbringing
Major Losses
Multiple Marriages

Please describe the kind of family you grew up in

COUNSELING HISTORY

If you have had any previous counseling, psychiatric treatment, substance abuse treatment, or residential/in-patient care, please list the name of the therapists and/or programs

Please include Name of Therapist/Program, Issues Addressed, and Dates in Treatment

Treatment

Has anyone in your family ever been treated or hospitalized for substance abuse, mental health issues, or psychiatric conditions? Yes No

If yes, please describe

Have any of your family or friends ever attempted or committed suicide? Yes No

If yes, who and when

MEDICAL HISTORY

Name and Town of Current Physician

Date and outcome of last physical exam

Please list any conditions, illnesses or surgeries that might be relevant to your reason for seeking counseling

Please list current medications you are taking even if use is seldom or as needed

Please include Name of Medication, Dosage, and Reason for taking medication

Current Medications

PRESENT ISSUES AND GOALS

Select any of the flowing symptoms or problems that you are currently or have recently experienced

Symptoms Stress
Grief
Verbal abuse
Impulsive behavior
AnxietyAnxiety
Chronic pain
Sexual abuse
Controlling
Sexual problems
Fears
Loneliness
Sexual addiction
Obsessive thoughts
Depression
Panic
Compulsive behavior
Poor concentration
Shyness
Gender identity
Anger
Fatigue
Low self-esteem
Hearing voices
Loss of appetite
Bad dreams
Marital problems
Aggression
Racing thoughts
Trouble sleeping
Apathy
Relational issues
Eating problems
Physical Abuse
Unwanted memories
Alcohol use
Feeling worthless
Emotional Abuse
Loss of control
Pregnancy/Abortion
Work issues
Financial issues
Controlled by others
Drug use
Career choices
Loss
Indecisiveness
Spiritual apathy
Seeing/Hearing things others don’t

Please describe why you are coming to counseling (issues, problems, symptoms, how long, etc.)

Please check on the scale below to indicate how distressing your problems are to you Very minimal distress
Moderate distress
Very extreme distress

Are you currently experiencing any suicidal thoughts? Yes No

Have you experienced suicidal thoughts or attempted suicide in the past? Yes No

Are you currently experiencing any violent or homicidal thoughts? Yes No

Please describe thoughts

REFERRAL INFORMATION

How did you find us (referred by doctor, friend, family, internet, EAP or other)?

Thank you for filling out the Adult Intake form.

Please return to the form page to fill out the next required form.

< Back to Form Page

Caring, Confidential, and Professional Counseling for Northern Virginia

Court Related DUI Evaluations and Drug and Alcohol Evaluations

HOPE, A State Approved Parent Education Class

Shoplifting Interventions for Adults and Juveniles

Adult Intake