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Family Counseling Intake Form
Adult
Client #______________
Client Name____________________________ Date_______________
Preferred Name____________ Marital Status_______________ Date of
Birth________________
Gender________________ Race____________
Ethnicity______________Address_________________________________________________________________________________________________________
Contact Information (please circle preferences for appointment
reminders)
Home__________________________ Cell___________________________
Work_____________________________
Email____________________________________________________________________________________________________
Please check all problems that you are seeking counseling
for:
Anxiety Family Conflict
Depression Occupational Problems
Trauma Physical/Medical Problems
Childhood Trauma School/Academic Problem
Attention/Concentration Difficulties Stress
Child/Adolescent Behavior Problems Substance Abuse
Developmental Concerns Eating Disorder
Difficulty with Social Interactions Verbal/Physical
Aggression
Grief Spouse/Partner Conflict
Parenting Problems Other:
Please provide brief description of any checked problems
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Have you wished you were dead or wished you would go to sleep
and not wake up?
__________________________________________________________________________________________________________
Have you actually had any thoughts of killing yourself?
__________________________________________________________________________________________________________
Have you ever done anything, started to do anything, or prepared
to do anything to end your life?
If yes, how long ago did you do any of these things?
_______________________________________________________________________________________________________________
Have you previously received any mental health services? If yes,
please list
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Approved 04/27/2015
http://www.gway.org/
8/18/2019 FC Adult Intake Forms Fisa Adult
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Family Counseling Intake Form
Adult
Client #______________
Who is your primary doctor/pediatrician?
__________________________________________________________________________________________________________________
Do you have any current medical conditions? If yes, please
list
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Do you have any allergies? If yes, please list
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Have you ever been hospitalized overnight for medical reasons?
If yes please list
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Past and Current Prescriptions medications
Name Dosage Frequency Prescribing
doctor
Reason for taking
Over the Counter medications
Name Dosage Frequency Prescribing
doctor
Reason for taking
Approved 04/27/2015
http://www.gway.org/
8/18/2019 FC Adult Intake Forms Fisa Adult
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Family Counseling Intake Form
Adult
Client #______________
Do you use Alcohol? How often/much
_________________________________________________________________________________________________________
Do you use tobacco? What type? How often/much?
_________________________________________________________________________________________________________
Have you ever used illegal substances? What type? How
often/much?
_________________________________________________________________________________________________________
Have you ever received substance abuse treatment? If yes, please
explain
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Do you consider your substance use to be a problem? If yes,
please explain
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Approved 04/27/2015
http://www.gway.org/
