FREEMIND CONSULTANCY - Intake Form

INTAKE FORM

Name(*)

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Gender

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Date of birth(*)

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Adress

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City

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Phone (h)

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State

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Zip

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Cell

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E-mail

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Emergency Contact Person

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Phone

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Relationship to you

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Referred by

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Do you work

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Where

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Position

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Counseling History

Have you had previous counseling

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Explain why

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Reason for this appointment reqest today

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List any concerns you have

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Are you currently taking any medications

What

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Why

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Have you ever thought about, or attempted suicide

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Has anyone in your family, or friends committed, or attempted suicide

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What are your positives

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Please Complete if you have any disability

What type of disability do you have

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Do you have current documentation to prove your disability

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Who is providing the documentation

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(ie: Physician, Therapist, Psychiatrist, Psychologist, Special Education Program at school) What type of service and/or accommodations do you feel you will need at this time:

Personal History

Are you currently in a relationship

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Length of time

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Family physician

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City

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State

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Date of last physician visit

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Reason

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Current or past health issues you are concerned about

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What

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Hospitilizations

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Dates

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Why

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Any death or losses significant to you

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Who

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When

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Alcohol and Drug Use (Please Be Honest. This is Confidential)

Do you drink alcohol

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How often

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Used Frequency

Marijuana

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Crack

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Cocaine

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Tranquilizers

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PCP

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LSD

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Heroin

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Spice

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Ecstasy

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Family History

Name

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Relationship

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Sex

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Age

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Education/Occupation Living/Deceased

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Are your parents together

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Date of divorce/separation

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Military and School

Have you served in the armed forces

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When

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What branch

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Any other colleges/school

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When

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Where

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Provide any other concerns that you may have

Provide any other concerns that you may have:

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Our Privacy Commitment to You: Your privacy is protected by law, but we are also very concerned that you feel safe in sharing your information in the counseling office. Only people who have the legal right and need may see your information. Unless you give us permission in writing we will only disclose your information for purposes of treatment, payment, business operations, or when we are required by law to do so.

Client Acknowledgement

By signing below I am verifying that I have read and understood the privacy policy of Freemind Consultancy Center and the counselor’s professional disclosure statement.

INTAKE FORM

Counseling History

Please Complete if you have any disability

Personal History

Alcohol and Drug Use (Please Be Honest. This is Confidential)

Family History

Military and School

NEWSLETTER