Adult Intake Information The following information will become a part of your confidential file. This will help us to focus more clearly on the areas of concern that you may desire to work on in counseling. Please answer each question as completely and carefully as you can. If you’re in couples counseling at BCC, be aware this information will be shared with your spouse/partner in our work together as a team. Name Date of Birth Age Male Female Race Ethnicity Presently Living With: Parents Spouse Alone Other Other Occupation Hours Worked Weekly Employer Work Phone Home Phone Cell Phone Ok to leave voicemail: Home: Yes No Work: Yes No Cell: Yes No Email Ok to contact you by email? Yes No We need to alert you if you choose below to communicate with us by electronic transmission (texts, cell phone, faxes and/or emails) you assume the risk this may pose to client confidentiality. In this day and age of hackers, there is no 100% guarantee of confidentiality for any of us via electronic transmission. Thus, privacy of electronic transmissions cannot be assured. However, we’ll do our utmost to preserve your confidentiality on our end. Current Marital Status Single Married Remarried Separated Divorced Widowed U.S. Citizen? Yes No If no, please explain status: Emergency Contact Phone Relationship to Client EDUCATIONAL BACKGROUND Place an "X" on last year of school completed: High School: 9 10 11 12 College: 1 2 3 4 5+ Grad School: 1 2 3 4 5+ Any special programming in school? Describe any physical problems or handicaps you have that require medication or medical treatment: Are you currently receiving medical treatment? Yes No If yes, for what purpose? List medications and dosages you are taking for any physical problem Allergies? What Type? Have you used drugs for other than medical purposes? Yes No If so, what drugs? When was the last time you used? Have you been in counseling/therapy/mental health care before? Yes No If yes, when? For what reason? Psychiatric facility names and or Therapist Names Have any of your family members ever received counseling? Yes No If so what issues/problems were addressed? Have you ever taken medication prescribed for emotional reasons? Yes No When? For what reason? Are you currently taking medication prescribed for emotional reasons? Yes No If yes, what medication and dosage? For what reasons? Do you use alcohol? Yes No How frequently? Few times a year Once a month Several times a month Once a week Multiple times a week Daily Average amount consumed? Last used? Do you smoke: Cigarettes Cigars Chew Use Snuff Vape How Often? Quantity used on average? Last used? MARTIAL BACKGROUND Name of Spouse Occupation Is your spouse willing to participate in counseling? Yes No Uncertain Date of this marriage Ages when married: Husband Wife Have you ever been separated? Yes No If Yes, when? List all marriages, including current one, in order. Indicate your age at the time of the marriage, how long the marriage lasted, whether it was broken by death or divorce, and the basic reason for the break-up of the relationship, from your perspective. CHILDREN/STEPCHILDREN/ADOPTED CHILDREN Name Age Sex By which marriage Living at home Name Age Sex By which marriage Living at home Name Age Sex By which marriage Living at home Name Age Sex By which marriage Living at home Name Age Sex By which marriage Living at home Any miscarriages? Yes No Abortions? Yes No RELIGIOUS BACKGROUND Your denominational preference Active Inactive Spouses denominational preference Active Inactive What significant spiritual experiences have you experienced or are currently experiencing? FAMILY BACKGROUND Natural Parents: Remained Married Separated Divorced Never Married If parents separated or divorced, how old were you at the time? Father deceased? Yes No If yes, how old were you at the time? Mother deceased? Yes No If yes, how old were you at the time? Father remarried when you were age Mother remarried when you were age You lived with: Mother Father Adoptive Foster Other Other What kind of relationship did you have with your stepparents or foster parents? Natural father's occupation Natural mother's occupation Stepfather's occupation Stepmother's occupation Adoptive father's occupation Adoptive mother's occupation How many times was your father married? Your mother married? Rate your parents' marriage: Unhappy Happy Very Happy Their marriage lasted List your brothers and sisters (including step, adopted and/or half brothers or sisters) from the oldest to youngest, giving their names and ages. Place an "X" by the statements that best describe your family history: Warm relationship with father/mother/step-parent/adoptive/foster parent Warm relationship with brothers/sisters/step-siblings/half siblings/ adopted siblings Sibling rivalry Father/mother absent physically/emotionally Moved frequently Parental job/financial instability Relatives lived nearby Close relationship with grandparents/aunts/uncles/cousins Alcohol/drug abuse/other compulsive behavior by father/mother Addictive/compulsive behavior in other family members Chronic-physical, mental or emotional illness in family members Rigid, perfectionistic standards Frequent/excessive anger and conflict Physical/emotional/sexual abuse by family members In your own words, briefly describe the main problem which prompted you to seek counseling at this time. Have there been times when the problem got better or disappeared? Yes No What do you think helped? Were there times when the problem was especially bad? Yes No What made it bad? Are there other people who play a major role causing your problems? Yes No …or in helping you to cope with your problems? Yes No Explain briefly: Have you ever been arrested? Yes No If so, please explain Are you involved in any current legal proceedings? Yes No If yes, please explain PROBLEM AREAS In the following list, place one "X" next to each item which identifies something with which you have ever had a problem. Please place two "X"s by problem areas of most concern to you currently. Anger It was a problem before It is currently a problem Bitterness It was a problem before It is currently a problem Depression It was a problem before It is currently a problem Eating Difficulties It was a problem before It is currently a problem Education It was a problem before It is currently a problem Fearfulness/Anxiety It was a problem before It is currently a problem Financial problems It was a problem before It is currently a problem Marital problems It was a problem before It is currently a problem Physical problems It was a problem before It is currently a problem Physically hurting yourself It was a problem before It is currently a problem Problems with social relationships It was a problem before It is currently a problem Problems with children It was a problem before It is currently a problem Problems with parent(s) It was a problem before It is currently a problem Religious/Spiritual concerns It was a problem before It is currently a problem Obsessions/Compulsions It was a problem before It is currently a problem Abortion It was a problem before It is currently a problem Perfectionism It was a problem before It is currently a problem Self esteem It was a problem before It is currently a problem Sexual concerns It was a problem before It is currently a problem Thoughts of hurting others It was a problem before It is currently a problem Thoughts of suicide It was a problem before It is currently a problem Trouble making decisions It was a problem before It is currently a problem Unhappy most of the time It was a problem before It is currently a problem Use of alcohol It was a problem before It is currently a problem Use of alcohol or drugs by family member It was a problem before It is currently a problem Use of drugs It was a problem before It is currently a problem Use of tobacco It was a problem before It is currently a problem Work/Unemployment It was a problem before It is currently a problem Violence toward property, others or animals It was a problem before It is currently a problem Abuse issues: emotional physical sexual It was a problem before It is currently a problem Legal Problems It was a problem before It is currently a problem Specify Delusions / Hallucinations It was a problem before It is currently a problem Pornography/Sexual Addiction It was a problem before It is currently a problem Other It was a problem before It is currently a problem Specify PLEASE COMPLETE THE FOLLOWING: The most important thing to me is... I worry about... I have sometimes felt guilty about... I have been criticized for... What makes me angry is... My biggest mistakes were... What makes me nervous is... I often felt that mother... Sex to me is... I often felt that father... God to me is... What hurts me most is... My biggest problem in life is... My temper... If I could change something it would be... I secretly... My children... My signature below serves as my acknowledgement that the information I’ve given is accurate and that I accept the risks to client confidentially by choosing to engage in electronic communication with Breakthru Counseling & Consulting, P.C. (BCC). I voluntarily choose and ask that my typed name on the signature line(s) of this document legally represent my electronic signature Client Name (Please Print) Date Client Signature Client DOB
