wendy k adult intake form

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Contact S. WENDY KRITZER

Adult intake form

CLIENT INFORMATION to be completed by all new and any former clients who have not been seen for 12 months or more.

* Indicates required field

Primary Client(s) Full Name *

First

Last

Street Address *

City/Town *

Postal Code *

Cell Phone/Main Phone *

Home Phone *

Work Phone *

Other Phone *

Preferred method of contact *

Call Text

Age *

Date of Birth (MM/DD/YYYY) *

Gender *

Occupation *

Years of service *

Relationship status *

Emergency contact

Emergency Contact's Name *

First

Last

Emergency Contact's Phone Number *

Family Information: (Who you are residing with at this time. Ex. Mother, Father, Spouse, or Children).

Mother's Name *

First

Last

Mother's Age *

Spouse's Name *

First

Last

Spouse's Age *

Father's Name *

First

Last

Father's Age *

Children's Name(s) *

First

Last

Children's Name(s) *

Significant others *

Such as brothers, sisters, grandparents, step-relatives, half-relatives, please specify relationship.

Please answer only the questions that apply, or that you are comfortable answering. The facts of this form will be held in the strictest confidence. If you are filling this form out on behalf of someone else, answers should be from the client’s perspective.

Personal History *

Briefly describe what brought you here today. Some examples might be: anger management, anxiety, depression, eating disorder, fear/phobias, loss or grief, self-esteem, suicide, self-injury, bullying, abuse, addictions, separation/divorce, parenting.

Approximately, how long have you had this concern *

What are your goals for counselling? *

Are there special, unusual, or traumatic circumstances that have affected your life? *

What strengths and qualities do you admire about yourself? *

Has there been a history of child abuse? *

Yes No

If yes, which type(s)? *

Sexual Physical Verbal

Medical/Physical Health

Please list any current health concerns: *

Medication(s) and Reason for Medication(s)? *

Physician’s Name: *

First

Last

Family history of medical problems *

Chemical Use History

Are you currently using any alcohol or drugs? *

No Yes

If yes, what are you using and how long have you been using? *

Describe any changes in your use patterns: *

Describe when and where you typically use substances: *

Describe how your use has affected your family or friends: *

include their perceptions of your use.

Reason(s) for substance use: *

Addiction Builds Confidence Escape Self-medication Social activity Taste

Check any boxes that you feel apply.

If a reason is not listed, please list it below *

Who or what has helped you in stopping or limiting your use? *

How do you believe your substance use affects your life? *

Does/Has someone in your family present/past have/had a problem with drugs or alcohol? *

No Yes

If yes, please specify who and why someone has/had a problem with drugs/alcohol *

Have drugs or alcohol created a problem for your job/personal life? *

No Yes

if yes, specify how have drugs/alcohol created a problem for your job/personal life? *

Counselling/Prior Treatment History

Are you seeing another counsellor at this time? *

No Yes

Current or Prior Psychiatric treatment? *

No Yes

If yes, please describe the psychiatric treatment *

Do you feel suicidal at this time? *

No Yes

if you are suicidal at this time please elaborate *

Hospitalizations? *

No Yes

if yes, please describe the hospitalization *

Have you had counselling prior to today? *

No Yes

if yes, please describe the counselling *

Suicidal thoughts/attempts? *

No Yes

If Yes, please describe the suicidal thoughts/attempts *

Drug/alcohol treatment? *

No Yes

if yes, describe the drug/alcohol treatment *

Involvements with self-help groups? *

No Yes

Such as AA, Al-Anon, NA, etc

If yes, please elaborate on your involvements with any self-help group(s) *

Any additional information that would assist in understanding your concerns or problems? *

Finally, Who/what referred you to The Counselling Corner? *

Relative Friend Website Facebook Kijiji Phone book Other

BY CLICKING "SUBMIT" THE CLIENT AGREES TO SHARE THE INFORMATION ENTERED THROUGHOUT THIS FORM WITH S. WENDY KRITZER. ALL ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE BESIDES THE THERAPIST.

SIGNATURES WILL BE GATHERED UPON THE INITIAL APPOINTMENT.

Submit

THE COUNSELLING CORNER

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Home
Find your counsellor
Rates
Intake Forms
Join our team

Contact S. WENDY KRITZER

Adult intake form

BY CLICKING "SUBMIT" THE CLIENT AGREES TO SHARE THE INFORMATION ENTERED THROUGHOUT THIS FORM WITH S. WENDY KRITZER. ALL ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE BESIDES THE THERAPIST.​SIGNATURES WILL BE GATHERED UPON THE INITIAL APPOINTMENT.

THE COUNSELLING CORNER

BY CLICKING "SUBMIT" THE CLIENT AGREES TO SHARE THE INFORMATION ENTERED THROUGHOUT THIS FORM WITH S. WENDY KRITZER. ALL ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE BESIDES THE THERAPIST.

SIGNATURES WILL BE GATHERED UPON THE INITIAL APPOINTMENT.