Intake Form

Date

Phone

Gender

Name

Age

Date of Birth

Relationship Status

Ethnicity EthnicityAsian/Pacific IslanderAmerican IndianWhiteHispanicBlackOther

Address

City

State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

May We Leave A Message? May We Leave A Message? Yes No

Referral Type Referral TypeSelfFriendFamilyOther

Please Specify

Healthcare Provider or Counselor

Have you previously been involved in counseling? Have you previously been involved in counseling? Yes No

Do you currently use alcohol or other non-prescription drugs? Do you currently use alcohol or other non-prescription drugs? Yes No

Is there a history of mental health problems in your family? Is there a history of mental health problems in your family? Yes No

Have you ever been physically abused? Have you ever been physically abused? Yes No

Have you ever been emotionally abused? Have you ever been emotionally abused? Yes No

Have you ever attempted suicide? Have you ever attempted suicide? Yes No

Have you ever been hospitalized for mental health reasons? Have you ever been hospitalized for mental health reasons? Yes No

Is there a history of alcohol or drug problems in your family? Is there a history of alcohol or drug problems in your family? Yes No

Have you ever been in legal trouble? Have you ever been in legal trouble? Yes No

Have you ever been sexually abused or assaulted? Have you ever been sexually abused or assaulted? Yes No

Are you currently taking any prescription medications? Are you currently taking any prescription medications? Yes No

Describe the concerns you would like to discuss with a TCRN counselor:

How long has this problem persisted?

Under what condition do your problems get worse? better?

Counselor Notes:

How serious do you consider your present concern(s)? 1-Not at all; 2-Mildly; 3-Moderately; 4-Highly How serious do you consider your present concern(s)? 1-Not at all; 2-Mildly; 3-Moderately; 4-Highly 1 2 3 4

How motivated are you to resolve your concern(s)? 1-Not at all; 2-Mildly; 3-Moderately; 4-Highly How motivated are you to resolve your concern(s)? 1-Not at all; 2-Mildly; 3-Moderately; 4-Highly 1 2 3 4

How optimistic are you that your concern(s) can be resolved? 1-Not at all; 2-Mildly; 3-Moderately; 4-Highly How optimistic are you that your concern(s) can be resolved? 1-Not at all; 2-Mildly; 3-Moderately; 4-Highly 1 2 3 4

Religious Affiliation Religious AffiliationJewishCatholicProtestantChristianBaptistLutheranNone, but I believe in GodAtheist or agnosticOther

Please Specify

If you are currently taking any medication(s), please list the type, dosage, and the purpose for each below:

Please read the following symptoms and mark those to which apply. Please read the following symptoms and mark those to which apply. Headache Dizzyness Fainting Spells No Appetite Over-Eating Stomach Trouble Bowel Distrubances Always Tired Always Sleepy Unable To Relax Insomnia Recurrent Dreams Nightmares Hallucinations Inferiority Feelings Feel Tense Feel Panicky Fears and Phobias Obsessions Depressed Suicidal Ideas Take Tranquilizers Alcoholism Dangerous Drugs Allergy Asthma Homosexuality Sexual Problems Shy With People Can't Make Friends Afraid Of People Home Conditions Bad Unable To have A Good Time Always Worried About Something Don't Like Weekends/Vacations Can't Make Decisions Over-Ambitious Financial Problems Gambling Job Problems Can't Keep A Job Other

Please describe any medical conditions that you have:

Is there anything else you would like us to know about you?

I Read Consent for Biblical Counseling at the top of the page I Read Consent for Biblical Counseling at the top of the page Yes

I Read Client Notification of Privacy Rights at the top of the page I Read Client Notification of Privacy Rights at the top of the page Yes

Signature (First and Last Name)