Davis Counseling

Home Contact Insurance Intake 1 Intake 2 Cancellation Form Blog

Today’s Date

Name Age Date of Birth_________________________________

Address_____________________________________________________________________________________________

Phone priimary: Phone secondary___________________________________________

E Mail_______________________________________________________________________________________________

Race Where did you grow up?_________________________________________

Marital/Relationship Status______________________________________________________________________________

Education Occupation SSN_____________________

Partner’s Name Age Occupation________________________________

Religion(background, beliefs, involvement)_________________________________________________________________

Emergency Contact/Phone number/relationship______________________________________________________________

Closest Relationships age sex relationship living with you

Name_______________________________________________________________________________________________

Please describe your current living situation:(do you live with others?)____________________________________________

____ _

I would describe my friendships as: ____close _____somewhat close _ _distant __ _conflicted________other

Have you participated in therapy before? Y N Reason:_____________________________________________

____________________________________________________________________________________________________

Are you currently seeing a psychiatrist? Y N
Have you or a family member ever been hospitalized for mental or emotional issues? Y N

If yes, please explain: dates, where,reason:________________________________________________________________

___________________________________________________________________________________________________

Substance abuse or addiction history? ___ N ___Y (please explain)______________________________________________

____________________________________________________________________________________________________

Legal History (arrests , prison , DWI ?)_____________________________________________________________________

MEDICAL INFORMATION: Doctor’s name and phone:__________________________________________________________

Are you on any medications? ___Y ___N If so, what, how much, why ?___________________________________________

PRESENTING PROBLEM: State the nature of the problem in your own words:_______________________________________

_____________________________________________________________________________________________________

Your most difficult relationship is________________________________________________________________________

Your most difficult emotion is___________________________________________________________________________

What are your two most important goals for therapy ?

1._________________________________________________________________________________________________

2._________________________________________________________________________________________________

FAMILY INFORMATION: How many siblings do you have?________

How would you describe your relationship?_________________________________________________________________

Describe your relationship with your mother and father:______________________________________________________

___________________________________________________________________________________________________

CRISIS INFORMATION: Any current suicidal thoughts, feelings or actions ? Y________ N__________

If yes, explain________________________________________________________________________________________

___________________________________________________________________________________________________

Significant losses?_____________________________________________________________________________________

___________________________________________________________________________________________________

Anything else you feel important that I should know about?____________________________________________________

___________________________________________________________________________________________________

Who refered you to this practice ? _______________________________________________________________________

Thank you for taking the time to fill out this information sheet. This will be reviewed and used to best assist you in your psychotherapeutic work.