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Diagnostic Form
This form is an in-depth intake document that needs to be completed prior to our first session
Step
1
of
6
16%
New Counseling Client lntake Form
Client Contact lnformation
Date
MM slash DD slash YYYY
Name
First
Middle
Last
Phone
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
May I send mail to your mailing address?
No
Yes
May I send you emails?
No
Yes
May I leave a detailed message on your phone?
No
Yes
home phone
May I leave a detailed message on your phone?
No
Yes
cell phone
May I leave a detailed message on your phone?
No
Yes
work phone
May I send text message to your phone?
No
Yes
cell phone
Date of Birth
Month
Day
Year
Highest Level of Education:
Occupation/Employer:
Student Status:
School/College
Religion/Spirituality:
First Choice
Second Choice
Third Choice
Relationship Status:
Single
Married
Partner/Significant Other
Divorced
Widowed
Other
Emergency Contact Person:
First
Last
Relation:
Phone:
Referral Source:
Primary Insurance
Insurance Plan Name:
Insured Name:
First
Middle
Last
Suffix
Subscriber ID#:
Co-payment (if known):
Address of where to file insurance:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Background Information:
Name of Primary Physician:
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Physician Phone#:
List Any Medical Problems:
List Current Medications:
List Any Medical Hospitalizations:
Mental Health:
Prior Mental Health Treatment:
Name of Former Provider(s):
First
Last
Have you ever undergone a psychiatric hospitalization?
No
Yes
Hospital Name:
Hospital Name:
Hospital Address:
City
State / Province / Region
Date of hospitatlization:
Month
Day
Year
Name you used when admitted:
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
May I, as your therapist, be granted permission to access your records from your hospitalization(s)?
No
Yes
Have you ever attempted suicide?
No
Yes
Family Members with Mental Health Conditions:
Family Members with History of Suicide:
Family Members with History of Attempted Suicide:
Family Members with History of Substance Abuse:
Substance Abuse History:
Have you ever attempted suicide?
No
Yes
Additional Information:
How often do you smoke:
Never
Monthly
Weekly
Daily
How often do you drink alcohol:
Never
Monthly
Weekly
Daily
How often do you use drugs:
Never
Monthly
Weekly
Daily
Have you ever been charged with DUI:
No
Yes
Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Where were you charged with DUI?
City
State / Province / Region
Where were you charged with DUI?
City
State / Province / Region
Are you currently involved in any legal proceeding or court case related to alcohol or any other reason?
No
Yes
History of Abuse/Trauma
Have you ever been abused Sexually?
No
Yes
Have you ever been abused Verbally/Emotionally?
No
Yes
Have you ever been abused Physically?
No
Yes
Have you ever had any Other Trauma?
No
Yes
Please descripe the trauma:
Relationship History
Past Significant Relationships:
Previous Marriage(s)
Current Information
Sleep Issues
Difficulty Sleeping?
No
Yes
Sometimes
Trouble Falling Asleep?
No
Yes
Sometimes
Frequent awakening during the night?
No
Yes
Sometimes
Awakening early in the morning?
No
Yes
Sometimes
Take medications for sleep?
No
Yes
Sometimes
What medication(s) do you take for sleep?
Do you typically wake up rested?
No
Yes
Sometimes
Do you struggle with daytime fatigue?
No
Yes
Sometimes
Do you take naps during the day?
No
Yes
Sometimes
Do you have a set/regular sleep schedule?
No
Yes
Sometimes
How many hours do you sleep each night?
Is it a sufficient amount of hours?
No
Yes
Sometimes
Health Concerns
Any current health concerns?
No
Yes
Additional information aobut your health concernts:
Social Media
How much time do you spend on the internet each day?
(ex. Facebook, Twitter, Instagram, Snapchat, etc.)
Do you prefer to text, talk on the phone or to communicate in person?
Text
Talk on the Phone
Communicate in Person
Do you use social media to access pornography?
No
Yes
Do you think your use of social media impacts/interferes with your current relationship?
No
Yes
Possibly
Which relationship(s) does it impact the most?
(i.e. spouse/partner, children, etc.)
Additional Concerns
Current Family Concerns?
No
Yes
Additional Information:
Current Financial Concerns?
No
Yes
Additional Information:
Current Legal Concerns?
No
Yes
Additional Information:
Current Work/School Concerns?
No
Yes
Additional Information:
Presenting Problem
Presenting Problem(s):
Counseling Goal(s):
Additional information about any experience/life transitions/situations:
DSM Diagnosis:
(reference)
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