Welcome...

I'm glad you're here! Before we begin working together please fill out this form to allow me to get a thorough understanding of how I can best serve you. Everything in this form will remain confidential with the following exceptions: (a) you direct me in writing to disclose information with someone else, (b) it is determined you are a danger to yourself or others (including child or elder abuse), or (c) we are ordered by a court to disclose information. I look forward to learning more about you as we begin our work together!

Counseling Intake Form 

Phone

919-749-1611

Email

​Presenting Problem

Rate the intensity of this problem (1 being mild and 5 being most severe)

Current Symptoms:

Have you ever contemplated committing suicide?
Hav you experienced thoughts of suicide in th last 30 days?
Are you a survivor of trauma?
Are you pregnant now?
Are you at risk for HIV/AIDS/Sexually Transmitted Diseases? (Unsafe Sex / Using Needles?)
Has your physical health prevented you from participating in activities?

Substance Use:

Have you ever used any form of tobacco, such as cigarettes, snuff, chewing tobacco, etc.)
Are you a former tobacco user? If yes, what form(s) of tobacco have you used in the past? (Please check all that apply)
Have you been in a program to help you quite using tobacco in the last 30 days?
Would you or someone you know say you are having a problem with alcohol use / addiction?
Would you or someone you know say you are having a problem with pills or illegal drugs?
Would you or someone you know say you are having problems with other addictions, like gambling, pornography, or shopping?
Have you ever been to a self-help group?

Substance Use Past:

Would you or someone you know say you had a problem with alcohol use or addiction?
Would you or someone you know say you had a problem with pills or illegal drugs?
Would you or someone you know say you had problems with other addictions, like gambling, pornography, or shopping?
Is there a history in your family of addiction

Personal, Family, & Relationships:

Have you ever been arrested?
If yes, did you serve time in prison or a corrections facility?
Has a significant person or family member entered into your life or left your life in the last 90 days?
What is your marital status now? (Please check all that apply)
Have you ever had problems in your marriage or relationships?
If yes, please check a reason why:

Education

Work:

What is your work history like?
How long do you usually stay in your job?
Have you ever served in the military?
If yes, what is your status?

Medical:

Have you ever been to a mental health professional before?

Spirituality and Faith, Belief, Meaning:

Do you consider yourself spiritual or religious?
On a scale of 0 (not important at all) to 5 (extremely important), how you would rate the importance of faith, belief, or spirituality in your life?
Have your beliefs influenced you in how you handle stress?
Are you part of a spiritual or religious community?