Intake Form For Online Counseling

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PRIVACY STATEMENT: Any information provided by a client via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.
Today's Date 
CLIENT INFORMATION
Last Name First Name Middle Initial
  
Marital Status Birth Date Age Gender
   
US Drivers License State/# Occupation Employer
  
Street Address P.O. Box
 
City State Country/Province Postal Code
   
Home Phone # Other Phone # Skype Username
  
Can we leave a message on your home phone? 
Can we leave a message on your other phone? 
Email Address: 
   
PHYSICIAN NAME: 
   
Current Medications: 
REQUESTED SERVICE INFORMATION
What service(s) is requested at this time? Counseling: 
What concern has prompted you to contact me at this time?
Why are you interested in Distance Counseling rather than Traditional Face-to Face Counseling at this Point?
Please check all that you have experience with:
What type of platform does your computer use?
  Other
What type of internet access do you have?
IN CASE OF EMERGENCY
Who should be contacted in case of emergency?  
Relationship to Patient Home # Work Phone #
  
INTAKE/BACKGROUND INFORMATION
Have you have received treatment from a Psychiatrist or Counselor in the past?  
Have you ever been Hospitalized for a Psychiatric Illness; Alcohol or Drug Treatment; or a Suicide Attempt?  
If you answered YES to either question above, when and where were you treated and for what problem (s)? Please list dates, diagnosis and circumstances.
What was the result of this treatment?
Are you currently being treated by a therapist, counselor, or psychiatrist? 
What symptoms are you experiencing at this time? For example Depressed; Anxious; Sad; Angry
Have you have received treatment from a Psychiatrist or Counselor in the past?
What have you already tried for this problem?
Have you tried anything that DOES HELP? 
If YES what DID help?
How often do you drink alcoholic beverage?  
   
How often do you use recreational drugs? 
Please list below all recreational drugs you use.
If you are married or have a "significant other" or long term partner, how long have you been together? Please describe the relationship:
If you have any children, please list their names and ages:
Name:  Age: 
       
Name:  Age: 
       
Name:  Age: 
       
Name:  Age: 
Who lives in the household with you?
Name:  Relationship: 
       
Name:  Relationship: 
Do you have any siblings? Please list where you fall in the birth order and what your current relationship is with them?
Are your parents alive and please describe your current relationship with them?
Who in your present life do you usually talk to when you have problems or feel upset?
How much education have you completed?  
Are you happy with your current job/career?  
If not, why?
Are there any medical problems now or in the past that would be helpful for me to know about? Please describe:
Have you ever been arrested or convicted of a crime?  
If YES, please explain:
It would be helpful to know about your family of origin, what your childhood was like, and anything else about what your family and life were like when you were growing up. If your past history includes abuse of any type, please include this.
Where you ever Physically, Sexually, Emotionally or Mentally abused as a child? If your past history includes abuse of any type, please include this. If your past history includes any type of trauma please include it. Please include who abused you.
Have you ever felt in the past like harming yourself or somebody else?  
Do you have those feelings now?  
Is there anything else I should know?
AGREEMENT
I have read and completed this form truthfully and accurately as to the best of my knowledge. I have also read Awakenings Counseling Center's Informed Consent and Privacy Practice Statement. By submitting this form I understand that I am financially responsible for the payment of all services prior to them being rendered to me. I understand that ACC does not file my insurance for Distance Counseling. I understand that it is ACC's policy that I will be charged a $55.00 fee for any appointment that I do not cancel at least 24 hours in advance. Additionally I will pay for the failed appointment prior to my next appointment.
(Box must be checked before request can be sent.)
Please click on the Submit Form button to submit this information.