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2nd Star Counseling Intake Form

2nd Star Counseling Intake Form

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Published by AThompsonCO
www.2ndStarCounseling.com

Copyright and All Rights Reserved 2012
www.2ndStarCounseling.com

Copyright and All Rights Reserved 2012

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Categories:Types, Business/Law
Published by: AThompsonCO on Nov 19, 2012
Copyright:Attribution Non-commercial

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09/26/2013

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Date: _____________1
2
nd
Star Counseling, LLC
Kathryn Raley, Psychotherapist PO BOX 277Secondary Education, B.S. Lafayette, ColoradoMA Community Counseling, Regis University 80026Certificate counseling, Youth and Adolescents 720-515-8796NCC
Confidential Client Intake Form 
 
Name: ______________________________________________________________________________________ Date of Birth: ____________ Age: ________ Gender: ___________________________________________ Marital/Relational Status: __________________ Partner/Spouse Name: ________________________________ Children (Names and ages):_____________________________________________________________________ Others living in your home ______________________________________________________________________ Occupation: ______________________________ Highest Level of Education: ____________________________ 
CONTACT INFORMATION
 Address: ______________________________ Phone number(s): _____________________________________  ___________________________________ At which number(s) may I leave a message?________________ 
EMERGENCY CONTACT
Name: ________________________________ Relationship to you: __________________________________  Address: ______________________________ Phone: _____________________________________________  ______________________________________ Alternate phone:______________________________________ 
EXPECTATIONS FOR THERAPY
What brings you to seek therapy now and what do you hope to gain? _________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________ 
 
Date: _____________2
What are your concerns about therapy? __________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________ If you have had an experience with therapy in the past, can you briefly describe what worked for you or what you
didn’t work?
 _________________________________________________________________________________  ___________________________________________________________________________________________ 
PAST YEAR CHECKLIST
Only respond to those areas that apply to you. Please rate the level of distress these issues have caused you in thepast year:
0 1 2 3 4None Minor Moderate Considerable Extreme ____Sleeping Too Much/Too Little ____Eating Too Much/Too Little ____Mood Swings ____Angry Outbursts ____Depression ____Repetitive Behaviors ____Anxiety/Fear  ____Lack of Energy ____Hear/See things others cannot ____Suicidal Thoughts/Actions ____Physical/Emotion/Sexual abuse ____Drug/Alcohol (self or other) ____Loneliness ____Caring for others ____Distance from Loved Ones ____Death/Major Loss ____Past trauma ____Health Problems ____Sexual Problems ____Relationship Problems ____Concerns regarding family ____Education/Work Concerns ____Financial Concerns ____Legal Difficulties ____Major Life Transition ____Gender Identity Conflict ____Sexual Identity Conflict ____Cultural Concerns ____Religious Conflicts ____Experienced Discrimination
MEDICAL AND MENTAL HEALTH TREATMENT INFORMATION
Please describe your physical and mental health including significant hospitalizations, illnesses, and/or medications. ________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________  Are you currently receiving other mental health services or medical treatments? ___________________________________________________________________________________________  ___________________________________________________________________________________________ 
 
 
Date: _____________3
SUBSTANCE USE
 
Do you currently use tobacco, alcohol, or other drugs? _____________________________________________ Substance How much and how often? Past Use _____________ _________________________________ ______________________  _____________ _________________________________ ______________________  _____________ _________________________________ ______________________  _____________ _________________________________ ______________________ (If applicable) When you used the most, how much did you use? ________________________________________  ___________________________________________________________________________________________ Past substance abuse treatment? ________________________________________________________________ 
LEGAL HISTORY
 
 Are you involved in the legal system or have you had significant legal issues in the past? ___________________________________________________________________________________________  ___________________________________________________________________________________________ 
FAMILY INFORMATION
 
Please give me a brief family history. Describe family of origin and your current family dynamics: ___________________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________ 
RELATIONSHIPS WITH OTHERS
 Please describe the important people in your life and the quality of these relationships: ___________________________________________________________________________________________  ___________________________________________________________________________________________  ___________________________________________________________________________________________ 

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