Adult Initial Intake Form

WHY THESE QUESTIONS? Lighthouse Christian Counseling wants to make sure your paid session is focused on your direct needs. These questions help the counselor maximize their time in session with you by reducing the number of closed-ended questions they have to ask you. Please reach out to the office at (970) 413-8998 if you have any questions or difficulties!

Today's Date*

Your Name*

First Last

Your Phone Number*

Your Email*

Preferred Method of Communication*

Call
Text
Email

Relationship to Client*

Client Name*

First Last

Client Phone (If different than above)

Client's Date of Birth*

Client's Sex*

Client's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Counselor you will be seeing*

Why are you here today?*

My main symptoms are related to:*

Define your other*

The major stressors that precipitated my symptoms are:*

Check all that apply

If you said, other, please define*

My 3 biggest issues at present are:*

Have you had similar and significant symptoms in the past?*

When?*

Did they recently increase?*

If yes, when and what caused it?*

Have you had any other significant life events you might want to talk about?*

If yes, what?*

Prior Psychiatric Hospitalizations?*

If yes, when and for what reason?*

Past Counseling History?*

If yes, please list therapist, reason, and dates:*

Substance Abuse History?*

If yes, list what substances and when started*

List treatment Locations and Dates:*

Have you experienced any physical, sexual, or emotional abuse?*

If yes, please list:*

Any brain injuries? (concussion, asphyxia, other injury)*

Was the injury the result of birth complications?*

Severity of brain injury?*

Post-injury symptoms or problems [e.g., cognitive, psychological (anxiety, anger, depression)]?*

Was rehabilitation involved?*

Any previous psychological or neuropsychological evaluations? If yes, please list.*

Have you ever attempted suicide?*

If yes, please explain:*

Have you ever been hospitalized for attempted suicide?*

Current Prescribed Medications*

Please list: medications/dosage, reason taken, reactions and side effects, and date prescribed.

List any over the counter medications and/or supplements you are currently taking?*

Significant Allergies:*

Employer History*

List your last 3 employers, dates of employment, reason for leaving, and any other notes you find significant.

How would you describe your exercise?*

Sedentary (No Exercise)
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e., work or recreation 4-5x/week for 30-50 minutes)
Regular vigorous exercise (i.e., work or recreation 5-7x/week for 50+ minutes)

How would you describe your sleep?*

Insomnia (no consistent or sound sleep)
Little Sleep (i.e., 2-4 hours per day)
Limited Sleep (i.e., 4-6 hours per day.)
Regular Sleep (7 hours or more per day on average)

Are you dieting?*

How many meals do you eat in an average day?*

Do you have concerns about your eating patterns or habits?*

If yes, what is your height and weight?*

Which forms of Caffeine do you consume?*

How many cups/cans per day?*

Do you drink Alcohol?*

What kind?*

How many Drinks per week?*

Are you concerned about the amount you drink?*

Have you ever "passed out” or experienced blackouts?*

Do you occasionally "binge" drink?*

Have you driven after drinking?*

Do you use any Nicotine? (This includes patches, gum, vaping, etc.)*

If yes, what kind?*

Are you sexually active?*

Any discomfort or dysfunction with intercourse?*

Frequency per month*

Any Concerns?*

Is there anything you want me to know about your sexuality?*

Is there anything else you want me to know?*

How do you identify spiritually/religiously? (i.e., Christian, atheist, Hindu, etc...)?*

Would you say you have a personal relationship with Jesus Christ?*

If yes, for how long?*

Do you attend a church?*

If yes, which church? And how often?*

Do you pray and/or meditate?*

If so, how often?*

Do you read/study the Bible?*

If so, how often?*

Do you have personal concerns or questions related to God, the Christian faith, and/or the church?*

Are you open to discussing relevant matters of faith with your therapist?*

What is your current marital status?*

Spouse Name*

First Last

Relevant notes regarding spouse*

Children*

Please list for each child the following: Name, Sex, Date of Birth, Age, and relevant notes.

Are you here for Couple's Counseling?*

What are the issues you would like to work through?*

What have been the recent events leading up to seeking couple’s counseling now?*

Our three Primary Goals for marriage counseling are:*

When did you first think your problems were serious enough for couple's counseling?*

Please put a date, not a circumstance.

Date you met your current spouse

Date you began dating your current spouse

Date you were engaged

Date you were married

Date you were separated*

Premarital Counseling?*

Dates of Premarital Counseling*

Previous Marriage Counseling?*

Other Relevant Notes:

Do you have any other documents you want us to see?

Drop files here or

Max. file size: 256 MB.

Please upload any other documents that you would like us to see.

Comments

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Adult Initial Intake Form

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5236 Strauss Cabin Rd, Fort Collins, CO 80528
info@lighthousecounselingnoco.com