Let’s get things rolling First, fill out your forms! Adult Intake Questionnaire Adult Intake Questionnaire Legal Name * First Name Last Name Preferred Name How did you hear about us? (If referred by a doctor's office, friend, or former client we'd love to know who so we can thank them.) Details What brings you to counseling at this time? * What are the goals you would like to accomplish during counseling? * Please check any of the following you have experienced in the past six months. * (check all that apply) Eating too much Eating too little Excessive sleep Difficulty sleeping Fear Hopelessness Panic Guilt or shame Grief Restricting Anger Racing thoughts Trouble concentrating Difficulty making decisions Doing things over and over Recent life transition Low motivation Isolation from others Fatigue/low energy Low self-esteem Depressed mood Tearful or crying spells Anxiety Self-harm Binging Substance use issues Feeling overwhelmed Have you ever been hospitalized for a psychiatric issue? * Yes No In the past few weeks, have you wished you were dead? * Yes No In the past few weeks, have you felt that you or your family would be better off if you were dead? * Yes No In the past week, have you been having thoughts about killing yourself? * Yes No Have you ever tried to end your life? * Yes No Are you having thoughts of killing yourself right now? * Yes No Do you have thoughts or urges to harm others? * Yes No Does anyone in your family have mental health issues (even if not diagnosed)? * If you are in a relationship, please describe the nature of the relationship and months or years together. * Describe your current living situation. Do you live alone, with others. With family, etc… * Do you have any current or ongoing legal issues? * Yes No What is your level of education? Highest grade/degree and type of degree. * HS Diploma/GED Trade certification Some college Associates Bachelors Graduate Post-graduate Doctorate What is your current occupation? What do you do? How long have you been doing it? * What do you do for fun? (recreation, leisure, hobbies) * Conditions Be as comprehensive as possible; you'd be surprised as to what affects mental health! Physical? * Yes No Mental? * Yes No Disabilities? * Yes No Are there any accommodations you need for your therapy sessions? Who is your primary care physician? Please include type of MD, name and phone number. Specify all medications and supplements you are presently taking and for what reason. If taking prescription medication(s), who is your prescribing MD? Please include type of MD, name Do you drink alcohol? * Daily Weekly Often Sometimes Socially Rarely No/Sober Do you use other drugs or substances? * Daily Weekly Often Sometimes Socially Rarely No/Sober Have you seen a mental health professional before? * Yes No What else would you like me to know? * Thank you! EMC Questionnaire EMC Questionnaire Inner Piece Counseling - Sam Mitchell, LCMHCA NPI A21360 Legal Name * First Name Last Name DOB * MM DD YYYY Emergency Contact #1 Name * First Name Last Name Relationship: * Phone: * (###) ### #### Alternate phone: (###) ### #### Email: * Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Permission to: * leave voicemail send text messages send brief emails Do you have a second emegency contact you'd like to list? * Yes No Thank you! Continue on with your forms! Thanks, and we look forward to speaking with you!
