Counseling & Testing Intake Form

Counseling & Testing Intake Form - Adult – Page 4

CURRENT MEDICAL PROBLEMS:

	Diagnosis	Date Diagnosed	Physician

PAST MEDICAL PROBLEMS OR SURGERIES:

	Diagnosis	Date Diagnosed	Duration	Physician

MEDICATIONS:

	Medication	Dosage	Time you take them	Prescriber

Do you feel your medications are working?

NoYes

Any previous medication used?

NoYes, list

If yes, list

Have you stopped medications due to them not working or causing side effects?

NoYes, list

If yes, please list

Is there a family history of medical diagnoses?

NoYes, please list

If yes, please list

Are you receiving services from additional health care providers or specialists?

NoYes

If yes, please list their names and type of specialty e.g. occupational therapy, physical therapy, neurologist, etc.

Current substance use?

NoYes

If yes, please specify current substance use

Past substance use?

NoYes

If yes, please specify past substance use

Do you use tobacco and/or nicotine?

NoYes

Yes, If yes, how much

Is there a family history of substance use?

NoYes, please list

Yes, please list

Counseling & Testing Intake Form - Adult – Page 5

Have you received drug or alcohol counseling?

NoYes, please list

Yes, please list

Have you ever participated in a methadone or suboxone program (or a similar physician guided treatment for drug addiction?

NoYes

If yes, please explain

Are you able to complete age appropriate basic living responsibilities such as chores or hygiene tasks?

NoYes

Do you need cues to initiate these tasks?

NoYes

What do you do for exercise and how often do you do it?

How often do you shower?

If you take medications, do you need help remembering them?

NoYes

When is your bedtime?

When do you wake up?

Do you have trouble falling asleep or staying asleep?

NoYes

If yes do you experience any of the following?

As a child, were your parents:?

MarriedDivorcedSeparatedNever Married

As a child, what was the level of conflict between your parents?

Describe your childhood relationship with Mom

Describe your childhood relationship with Dad

If applicable, describe your childhood relationship with Step Mom

If applicable, describe your childhood relationship with Step Dad

Siblings – please list gender, age, quality of relationship with each

As an adult, identify all family members with who you have positive relationships

Who is in your support system friends, extended family, etc?

What are your current community resources YMCA, sports teams, clubs, church groups, etc

Counseling & Testing Intake Form - Adult

Presenting Problem(s):

Developmental History:

Assessment of Behavioral Health Domain:

Assessment of Abuse/Trauma:

Assessment of Medical Domain:

Assessment of Substance Use (10 and older)

Assessment of Basic Living Skills Domain:

Assessment of Family Domain:

Assessment of Social/Relationship Support Domain:

Assessment of Education Domain:

Assessment of Vocation Domain:

Assessment of Community/Legal Domain:

Assessment of Housing Domain:

Assessment of Financial Domain:

Assessment of Crisis/Risk Domain:

Assessment of Cultural/Religious Domain:

Clinical Treatment Goals: FOR THERAPY CLIENTS ONLY

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