Adult Intake "*" indicates required fields "*" Indicates required fields "+" Click to Add a New Line Name:* First Last Age:* DOB:* Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CONTACT INFOCell Phone Number:Work\Other Phone Number:May a message be left at this number?Cell: Yes No Work\Other: Yes No Email:* May you be contacted by Email?* Yes No Are you seeking group or family therapy?* Yes No SPOUSE/ PARTNER, OR CHILD'S INFOPlease, include spouse/ partner, or child’s information if seeking family therapy:Name: First Last Age: Cell Phone Number:Work/Other Phone Number:May a message be left at this number?Cell: Yes No Work\Other: Yes No Preferred way to be contacted: Cell Work/Other Email:* May they be contacted by Email?* Yes No EMERGENCY CONTACT INFOName:* Phone Number:*Relationship:* BACKGROUND INFOMarriages:If you have been previously married, please fill out the following section (Click on the + sign to add more than one marriage in the past.)Date Began:Date Ended:Ex Spouse Name:Children (Yes/No): Add RemoveFamily of Origin*Family of origin: List: parents, siblings, stepfamily, and any other significant family members. If seeking couples/family therapy please indicate both partners' family of origin information. If the person is deceased then put an “X” in the age box and indicate the date of death. Please, list your children in the next section.Name:Age:Relationship:City, State: Add RemoveChildren:List all children, including biological, adopted, foster, and step children.Name:Age:Relationship:City, State:Lives at Home (Yes/No): Add RemoveMarital/ Partner/ Relationship Status:*(Check all that apply) Single Married Divorced Separated Widowed Remarried Long-term Relationship Cohabitating Current Partner's Name: Partner's Occupation: Length of Relationship: How satisfied are you with your current relationship? (on a scale from 1-10, 1 being very unsatisfied and 10 being very satisfied)12345678910What is your occupation? Employer: Do you enjoy your occupation? Yes No Average hour worked per/week: Highest Level of Education: High School Some College College Degree Graduate School Other If you received a college/graduate degree, what was your degree in? If you are currently in school, what are you studying? How would you describe your spiritual or religious beliefs? Have you ever been involved in domestic abuse? Yes No If yes, please check all that apply:* Physical Emotional Sexual Neglect Other Do you have a primary care physician?* Yes No Physician Name:* Are you under the care of a psychiatrist?* Yes No Psychiatrist Name:* Are you under the care of a specialist?* Yes No If yes, please circle specialist(s) which provide you care:* Cardiologist Dermatologist Endocrinologist Gynecologist Infertility Specialist Nephrologist Neurologist Nutritionist Occupational Therapist Oncologist/Hematologist Orthopedic Specialist Pain Specialist Physical Therapist Psychiatrist Rheumatologist Sleep Specialist Urologist Other: Please list any chronic illness, diagnosis, medical conditions that you have been diagnosed with:Illness/Diagnosis:Dates: Add RemoveList all medications you are currently taking, including those you seldom use or take only as needed:Medication:Dosage:Treating: Add RemoveAre you taking the medications according to your doctor’s recommendation? Yes No If no, briefly explain:*Average Number of hours you sleep a night?*hoursHow long does it take you to fall asleep?min. hrs. Do you wake up in the night?* Yes No If yes, how often:*times per nightHow would you rate your overall sleep at the present time?*1 = poor and 10 = excellent12345678910Do you exercise on a regular basis?* Yes No If yes, how often:* If yes, please describe activity briefly:*How would you rank your overall diet on a scale form 1-10?*1 = poor and 10 = excellent12345678910Do you drink alcoholic beverages?* Yes No If yes how many alcoholic beverages do you drink:Weekly:Daily:Do you think you have a drinking problem?* Yes No Does anyone else think you have a drinking problem?* Yes No Do you smoke/vape?* Yes No If yes, how many cigarettes/packs per day do you smoke?Cigarette/ Vape:Packs/ Cartridges:What age did you start smoking?*Have you ever tried to quit?* Yes No Have you in the past or currently used abused, experimented with illegal drugs?* Yes No If yes, briefly describe:*Have you ever attempted/ seriously contemplated suicide?* Yes No If yes, describe briefly and indicate dates:*Have you ever had a psychiatric hospitalization?* Yes No If yes describe briefly and indicate dates:*THERAPY EXPERIENCES AND EXPECTATIONSAre you currently seeing another therapist?* Yes No If Yes, whom are you seeing?* Have you ever been in therapy in the past?* Yes No If yes, please fill out the following on your previous counseling experience(s):*Therapist:Location:Dates:Reason: Add RemoveWhat goals do you wish to accomplish during the therapy process?*Is there anything else you would think would be important for me to know about you or your family?Who referred you? May I contact him or her to thank them:* Yes No