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.








Presently Living With:
Parents
Spouse
Alone
Other








Ok to leave voicemail:
Home:
Yes
No
Work:
Yes
No
Cell:
Yes
No


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





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+



Are you currently receiving medical treatment?
Yes
No





Have you used drugs for other than medical purposes?
Yes
No



Have you been in counseling/therapy/mental health care before?
Yes
No




Have any of your family members ever received counseling?
Yes
No


Have you ever taken medication prescribed for emotional reasons?
Yes
No



Are you currently taking medication prescribed for emotional reasons?
Yes
No



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



Do you smoke:
Cigarettes
Cigars
Chew
Use Snuff
Vape




MARTIAL BACKGROUND


Is your spouse willing to participate in counseling?
Yes
No
Uncertain


Ages when married:


Have you ever been separated?
Yes
No


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













































Any miscarriages?
Yes
No

Abortions?
Yes
No

RELIGIOUS BACKGROUND







FAMILY BACKGROUND
Natural Parents:
Remained Married
Separated
Divorced
Never Married


Father deceased?
Yes
No


Mother deceased?
Yes
No




You lived with:
Mother
Father
Adoptive
Foster
Other











Rate your parents' marriage:
Unhappy
Happy
Very Happy


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


Were there times when the problem was especially bad?
Yes
No


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


Have you ever been arrested?
Yes
No


Are you involved in any current legal proceedings?
Yes
No


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

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

PLEASE COMPLETE THE FOLLOWING:


















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