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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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Published by: AThompsonCO on Nov 19, 2012
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09/26/2013

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Date: _____________

1

2
nd
Star Counseling, LLC

Kathryn Raley, Psychotherapist PO BOX 277
Secondary Education, B.S. Lafayette, Colorado
MA Community Counseling, Regis University 80026
Certificate counseling, Youth and Adolescents 720-515-8796
NCC


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 the
past year:

0 1 2 3 4
None 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:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Date: _____________
4
Have you now or ever experienced violence, abuse, or threatening behavior in a
relationship?_________________________________________________________________________________
TRAUMA HISTORY
Please list any past traumatic experiences you have had (including but not limited to childhood abuse, military
combat, assault, natural disasters, life threatening illness).

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
STRENGTHS AND RESOURCES
What helps you to make it through difficult times?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Who can you count on for support in times of need? _________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
What gives you personal enjoyment?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Tell me about special skills or abilities that you have.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Date: _____________
5
What communities are you a part of?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you have religious practices or spiritual beliefs that are important to you?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Is there anything else you think I should I know? _____________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

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