Alder and Oak Counseling, LLC Compassionate and Skilled Support on the Journey of Healing
We kindly ask your cooperation in answering the following questions below as accurate as possible since they will assist your counselor in assessing your needs pre-appointment. All information given will be kept confidential.
Client Information
Name
First Name
Middle Initial
Last Name
Name of parent/guardian (if under 18 years):
First Name
Middle Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Birth Place:
Age
Preferred Gender Pronoun
Please Select
He/Him/His
She/Her/Hers
They/Them/Theirs
Other
Relationship
What is your relationship status?
Married
Divorced
Separated
Single, never married
Widowed
Other
Please list any children/ages:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Please enter a valid phone number.
May we leave a message?
Yes
No
Cell Phone:
Please enter a valid phone number.
May we leave a message?
Yes
No
Email:
* Please note email correspondence is not considered to be confidential medium communication.
Emergency Contact:
Relationship with you:
Emergency Contact Phone:
Please enter a valid phone number.
Referred by (if any):
Current Living Arrangements (name of persons, age, relationship to you):
Presenting Issues/Problems (what brought you here?):
What do you hope to gain/accomplish in therapy?
Please indicate if there is a family history of any of the following conditions;
Yes
No
Indicate Family Member
Anxiety
Depression
Substance Abuse / Alcohol
Arrested
Obesity
Schizophrenia
Suicide Attempt
Domestic Violence
Have you previously received any type of mental health services?
Yes
No
Please list your previous therapist(s)
How was this helpful? What wasn't?
Current psychiatric provider:
Are you currently on psychiatric medication?
Yes
No
Please list psychiatric medicines that you took or are taking currently;
What is your employment status?
Employed
Unemployed
Retired
Self-employed
Disabled
Student
Homemaker
Other
Please give us general stressors that you are experiencing currently in your life:
Have you recently experienced any significant life changes:
Has your life ever been touched by adoption: Type a question
How would you rate your general happiness and well-being?
1
2
3
4
5
I often have;
suicidal thoughts
memory problems
sleeping disorder
struggled to explain myself to others
obsessive thoughts
violent thoughts
stress and tension
medical concerns
fatigue
work problems
Other
I often feel;
lonely
empty
sad
hopeless about the future
excessive guilt
suspicious
Other
Please check if you have experienced:
Depression
Sleep Issues
Suicidal thoughts
Suicide attempts
Self-harm
Anxiety
Panic Attacks
Poor concentration
Addiction
Dissociation
Nightmares/flashbacks
Isolation
Low energy
Anger/Rage
Grandiosity
Food/Body issues
Mood swings
Hyperactivity
Hyper sexuality
Aggressiveness
Hallucinations
Passive anger
ADHD
Other
Abuse History:
How often do you use alcohol and/or recreational drugs?
Daily
Weekly
Infrequently
Monthly
Never
Do you have recovery/support group involvement(12 step groups, church, meditation groups, etc.)?
Please provide family history of mental illness, trauma or substance use:
What do you consider some of your strengths?
List hobbies, interests or activities you enjoy?
People and/or animals you consider your support system:
Is there anything else you think it's important for us to know?
Client signature (I have answered these questions truthfully and accurately to the best of my knowledge):
Parent/Guardian signature (I have answered these questions truthfully and accurately to the best of my knowledge):
Submit
Should be Empty: