Hs Counseling Intake Form
Hs Counseling Intake Form
Hs Counseling Intake Form
Demographic Information:
Name: Date of Birth: Address: Home/Mobile Phone: Email: Occupation (if applicable): Year and Section: ER Contact Relationship: How were you referred? Emergency Contact Phone: If online, which website? Is it ok to leave a message for you at this number? Y / N Is it ok to email you? Y / N Date: Age:
Gender: M / F
Family Systems:
Father Mother Name: Age: Home Address: Cell No: Religion: Nationality Occupation: Work Address: Highest Education: School Attended: Marital Status of Parents: ___ Married ___Never Married ___Partnered ___Separated ___Divorced ___Widowed
Brothers and Sisters: (including client-ordinal position)
Name 1. 2. 3. 4. 5. 6. 7.
Age
Educational Attainment
Spiritual History:
Do you consider yourself to be religious? ___Yes ___No If yes what is your faith? If no, do you consider yourself to be spiritual? ___Yes ___No Religious upbringing: ________________________ Present Religious Group: Is this an important part of your life? _______ Why?
Emotional Status:
Are you currently experiencing strong emotions? _____ If yes, describe: _____________ Do you make decisions based on your emotions? _____ How well does that work for you? Did you have what you would consider to be childhood or other traumas? ___ If yes, describe: Have you been treated for emotional disturbances? ___ If yes, when? Have you had any thoughts of suicide? If so, when __________________ Do you have any thoughts now?
Are there any specific behaviors, actions, habits that you would like to change?
Present Situation:
Please state why you decided to come for counseling/therapy: What is the nature of your situation? What would you like to experience that is different from what you are experiencing now? How long has this been a problem for you? Please state what you would like to work in this therapy:
Personal Agreements
I understand that I may be asked to do certain homework exercises", such as reading, praying, changing behaviors, and otherwise acting in my own best interest. I understand that I am entirely responsible for my own actions and I will always make my own final decisions regarding counseling. I further understand that much of the work done will be to resolve issues and will depend on my honesty, and willingness to do the things I need to do to move forward even if it is painful and difficult. I understand that whatever I say in a session is strictly confidential and will not be released to anyone without my consent unless I am violating codes of abuse, harm to myself or others.
Rachel Eddins, M.Ed., LPC | 1501 Crocker Street, Suite One, Houston, TX 77019 | P: 832-338-6863, F: 713-630-0821