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Counseling Intake Form

Collects a new patient's personal, medical, and contact details ahead of their first counseling session to speed up the intake process.

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Patient Name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Date of Birth

Marital Status

Employment

Primary Care Provider

Referral Name

First Name

Last Name

Home Phone

Cell Phone

Preferred Method of Contact

Phone Email Text Message

Name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Relationship

Name of Insurer

First Name

Last Name

Insurer Phone Number

Subscriber Name

First Name

Last Name

Subscriber Date of Birth

Subscriber Relationship to Patient

Group Number

Policy Number

Please check all that apply

Anxiety Depression Sleep problems Appetite changes None of the above

Do you use tobacco?

Yes No

Do you use alcohol?

Yes No

Caffeine use?

Yes No

Have you been convicted of drug related charges?

Yes No

Please explain the circumstances

Are you currently taking prescription medication?

Yes No

Prescribing Doctor's Name

First Name

Last Name

Prescribing Doctor's Phone

Have you had any surgeries in the past 5 years?

Yes No

Please specify:

Family history

Depression Anxiety Substance abuse None

Why are you seeking treatment?

What do you expect from this counselling?

Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

Yes No

Therapist Name

First Name

Last Name

Reason for Seeking Help

Average Hours of Sleep per Night

Please describe any other experiences you have had problems with

Additional Comments or Concerns

By signing below, I confirm that the information provided in this form is accurate and complete

Date

Signature

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