Fill - Free fillable - Intake Form - Abma Counselling Services PDF form

ABMA COUNSELLING SERVICES

Confidential Client Information Form

Please use this form to provide your therapist with some basic information before your first

appointment. The information is confidential and will not be shared with anyone without

your written consent.

Today’s Date:

Name of Client:_____________________________ DOB: _________ Age: _______

Guardian Name (if applicable): _______________________________

Address: ___________________________________ Postal Code: ______________

Phone: _______________________ Email: _________________________

Emergency Contact:

Person to alert in the event of a medical emergency: __________________________

Relationship to you:_________________________ Phone: ____________________

Family Doctor: _____________________________ Phone: _________________

Referral Information:

Referred by: Internet search _____ Other (please specify): ______________________

General Information:

Current Occ

upation/Studies: ____________________________________________

Relationship Status: ____________________________________________

Name of Spouse/Partner: _____________________ Years in relationship: _____

Children (name/age): __________________________________________________

Reason For Counselling:

What main concern would you like to address in therapy? ______________________________

____________________________________________________________________________

How has this affected your life? __________________________________________________

____________________________________________________________________________

How long have you been experiencing this challenge? ________________________________

List any strategies you’ve used to try to cope with/overcome this challenge: ________________

____________________________________________________________________________

Symptoms:

Indicate “Yes” if you have you experienced any of the following:

Current Past

• Depressed m

ood ______ _____

• Anxiety ______ _____

• Phobias ______ _____

• Panic attacks ______ _____

• Angry outbursts ______ _____

• Sleep disturbances ______ _____

• Memory loss ______ _____

• Overuse of alcohol ______ _____

• Overuse of food ______ _____

• Addictions (______________) ______ _____

• Suicidal Thoughts ______ _____

• Intrusive thoughts (obsessions) ______ _____

• Obsessive behavior

s ______ _____

• Mood swings ______ _____

• Hallucinations ______ _____

• Frequent body complaints ______ _____

• Body image problems ______ _____

• Intrusive memories ______ _____

• Loss of appetite ______ _____

• Social withdrawal ______ _____

• Other __________________ ______ _____

Medical History

Have you had previous psychological care or counselling? If yes (a) when and (b) describe the

reason for seeking counselling previously: _________________________________________

___________________________________________________________________________

Have you ever received a diagnosis for a mental health-related concern? If yes, what was

the

diagnosis? __________________________________________________________________

Please provide the name and dosage of any medication you are taking:

____________________________________________________________________________

Have you ever been hospitalized for psychological problems? If yes, when?

____________________________________________________________________________

Have you had any s

ignificant or traumatic experiences that cause you concern at this time?

____________________________________________________________________________

If applicable, please note any addictive behavior (e.g. alcohol/substance abuse) and/or mental

health concerns (e.g. depression/anxiety) in your present family or family of origin:

____________________________________________________________________________

Physical Health Information

Do you have any medical conditions that are affecting your daily life:(ex. chronic illness, chronic

pain, traumatic injury, severe allergies, surgeries). Please provide dates when possible:

____________________________________________________________________________

List any past physical health concerns:

____________________________________________________________________________

List current medications (if any):

____________________________________________________________________________

Have you ever been in an automobile accident or head injury that is contributing to your current

condition? Describe:

____________________________________________________________________________

Is there any other information about yourself or your life circumstances that is important for us to

know?

____________________________________________________________________________

Thank you for completing this Intake Form. Click Submit to send the form.

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