Cove Counseling Intake Form

Counseling Intake Form
Patient Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth

Month Day Year
Date
Email
example@example.com
Home Phone
Cell Phone
Preferred Method of Contact

E-mail Home Phone Cell Phone
Employment
Marriage & Family Information
Marital Status
Spouse Name

First Name Last Name
# of Years Married
Spouse's Education
Spouse's Employment
Number of Children
Medical History
Please check all the apply

None Allergies Anemia Angina Anxiety Arthritis Asthma Atrial Fibrillation Benign Prostatic Hypertrophy Blood Clots Cancer Cerebrovascular Accident Cronary Artery Disease COPD (Emphysema) Crohn's Disease Depression Diabetes Gallbladder Disease GERD (Reflux) Hepatitis C Hyperlipidemia Hypertension Irritable Bowel Disease Liver Disease Migraine Headaches Myocardial Infarction Osteoarthritis Osteoporosis Peptic Ulcer Disease Renal Disease Seizure Disorder Thyroid Disease Other
Do you use tobacco?

No Daily Weekly Less Former User
Do you use alcohol?

No Daily Weekly Less Former User
Caffeine use?

No Daily Weekly Less Former User
Are you currently taking prescription medication?

Yes No
Please specify:
Family history

Adopted Alcoholism Allergies Asthma ArthritisBlood Disease CAD (Heart Attack) Cancer CVA (Stroke) Depression Developmental Delay Diabetes Eczema Hearing Deficiency Hyperlipidemia (High Cholesterol) Hypertension (High Blood Pressure) Irritable Bowel Disease Learning Disability Mental Illness Tuberculosis Obesity Osteoarthritis Osteoporosis PVD Renal Disease Other
Mental Health History
Please describe the issues with which you are struggling?
How do you hope counseling might help? (What are your expectations in coming here?)
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

Yes No
Therapist Name

First Name Last Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
Religious Background
Do you currently attend church regularly

Yes No
Are you a member of Fruit Cove Baptist Church

Yes No Decline
Briefly explain your religious background
Explain any recent changes in your religious/spiritual life, if any
*Your signature below indicates that the information you have provided above is truthful.
Date

Month Day Year
Date
Signature *

Clear
Should be Empty:

Counseling Intake Form

Marriage & Family Information

Medical History

Mental Health History

Religious Background