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ST. ANDREW COUNSELING CENTER
NEW CLIENT INTAKE
Name:_______________________________ DOB:_________________ Age:____________________________ Phone: Mobile:(____)__________________ Home:(____)____________________________________________ Address:_____________________________________________________________________________________ Email address:________________________________________________________________________________ Referred by:__________________________ Primary Physician:________________________________________ Emergency Contact:____________________ Relation: ______________Phone:(_____)_____________________ Member of St. Andrew United Methodist Church? ( ) Yes ( ) No.
In a few words, what are the issues/problems you are seeking help for today?
____________________________________________________________________________________________
Current Symptoms/Problem Checklist: Please check any symptoms…

( ) Depression
( ) Excessive worry ( ) Substance Abuse ( ) Increase risky behavior ( ) Avoidance ( ) Increased/decreased libido ( ) Hallucinations ( ) Loss/Bereavement ( ) Decrease need for sleep ( ) Suspiciousness ( ) Pain Issues
OTHER:_____________________________________________________________________________________

Suicide Risk
Have you ever tried to harm yourself in the past? ( ) Yes ( ) No.
Have you had any recent thoughts, or do you currently have any thoughts of suicide? ( )Yes ( )No.

Medical History:
List ALL current medications
and how often you take them/dosage:
Current over-the-counter medications or supplements:________________________________________________ Current/Past major medical problems (chronic illness, surgeries, hospitalizations…) ____________________________________________________________________________________________ Family History (Medical/Psychiatric Diagnoses, Substance Abuse or Self-Injury/Suicide): ____________________________________________________________________________________________ ____________________________________________________________________________________________ Past Psychiatric History:
Outpatient treatment ( ) Yes ( ) No. If yes, Please describe when, by whom, and nature of treatment.
____________________________________________________________________________________________
____________________________________________________________________________________________ Psychiatric Hospitalization ( ) Yes ( ) No. If yes, describe for what reason, when and where. ____________________________________________________________________________________________ ____________________________________________________________________________________________
Past Psychiatric Medications:
If you have ever taken any of the following medications:
(please circle).
Mood/Thoughts:
Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro, Viibryd, Effexor, Cymbalta,Wellbutrin, Remeron, Serzone,
Anafranil, Pamelor,Tofranil, Elavil, Tegretol, Lithium, Lamictal, Tegretol, Topamax, Seroquel, Zyprexa, Geodon, Abilify,
Clozaril, Haldol, Prolixin
Anxiety: Xanax, Ativan, Klonopin, Valium, Restoril, Librium,Tranxene, Buspar, Vistaril, Benadryl, Propranolol
Sleep: Ambien, Lunesta, Sonata, Rozerem, Restoril, Desyrel/trazodone
ADHD: Adderall, Concerta, Ritalin, Vyvanse, Focalin, Dexedrine, Strattera
Other: ______________________________________________________________________________________
Any positive/negative experiences with these medications? ___________________________________________
____________________________________________________________________________________________

Substance Use:
Do you (or others) think you may have a problem with alcohol or drug use? ( ) Yes ( ) No
Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No
If yes, for which substances and when/where were you treated?
________________________________________________
Days/wk drinking alcohol: __________ Avg. Number drinks/day: __________ Most drinks/day: _____________
Do you have current/past problems with the use/abuse of illegal substances? If so, which substances?
___________________________________________________________________________________________
Have you abused prescription medication? If so, which medications?
___________________________________________________________________________________________
How many caffeinated beverages do you drink a day? Coffee ___________ Sodas ________ Tea ____________
Tobacco History: active__________________________ past_______________________________________
Family Background and Childhood History:
Where were you born___________________________ where did you grow up ____________________________
Were you adopted? ( ) Yes ( ) No
Did your parents’ divorce? ( ) Yes ( ) No Your age at their divorce:_______ you lived with___________________
List your siblings and their ages: Sisters (ages)______________________________________________________
Brothers (ages)________________________________________________________________________________
Educational History:
What is your highest educational level or degree attained?
____________________________________________________________________________________________
Spiritual life: Do you belong to a particular religion or spiritual group?
____________________________________________________________________________________________

Trauma History:
Do you have a history of being abused emotionally, sexually, physically or by neglect? ( ) Yes ( ) No.

Occupational History:
Are you currently: ( ) Working ( ) Not working by choice ( ) Unemployed ( ) Disabled ( ) Retired
What is/was your occupation? ___________________________________________________________________
Have you ever served in the military? _______ If so, what branch and when? ______________________________
Relationship History and Current Family:
Are you currently: ( ) Married ( ) Divorced ( ) Single ( ) Widowed
How long? _____ Total number of marriages?______
If not married, are you currently in a relationship? ( ) Yes ( ) No If yes, how long? __________________________
Do you have children? ( ) Yes ( ) No. If yes, list ages and gender________________________________________
Legal: Do you have any pending legal problems?____________________________________________________
Other Information:___________________________________________________________________________

Source: http://hhiumc.squarespace.com/storage/pdf-files/Counseling%20-%20New%20Client%20Intake%20History.pdf

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