Name of Client
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Date of Birth
*
When were you born?
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Preferred Contact?
*
May we text or leave detailed messages?
*
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Relation to client
*
Policy holder's name
First Name
Last Name
Policy holders DOB
MM
DD
YYYY
Legal gender:
Client's relation to insured:
Self
Spouse
Child
Other
Member ID / Insurance ID
Type of Card
*
Visa
Mastercard
Discover
Other
If chose other, what type of card?
Please provide your card number, the expiration date, your card's security code, and also your billing zip code.
*
Your full name and age
*
Gender Identity
*
Option 1
Option 2
Marital Status
Married
Single
Widowed
Divorced
Never Married
Educational status and occupation (include length of time at current job)
*
People living in the home (include names, ages, and relation)
Children not living in home (include names, ages, and relationship)
*
Does the client currently feel safe in the home?
*
Have you ever been diagnosed with any mental health condition or received counseling or substance abuse concerns? (Condition, treatment, when? Was it beneficial?)
*
Are you or is anyone close to you concerned about your personal use of alcohol and drug use?
*
Please name the reasons as to why you are starting counseling.
*
Family members who have been diagnosed or received counseling for emotional or substance abuse concerns:
*
Please include name, relationship, condition, and treatment if possible
Is there anything that you would like their therapist to know about family or family members?
*
Are there any other significant individuals in your life currently or in the past? Who?
*
Name any significant life events that you have gone through
*
Examples include births, deaths, illnesses, moves, traumatic events, etcetera.
Have you experienced major problems in any of your relationships (Include romantic, family, peers)?
*
Are you a survivor of domestic violence or assault?
*
Have you ever been touched in a sexual way without your consent?
*
Are you currently or have you been treated for any serious medical conditions?
*
Please provide a list of your current medications with dosages and name of Dr. who prescribed the medication:
*
Have you ever intentionally tried to harm yourself? Do you have any thoughts about suicide?
*
Have you ever tried to harm someone else? Do you currently have any plans to do so?
*
Have you ever been arrested?
*
Are you on parole/probation?
*
Does the client have any legal charges pending? If so, please explain.
*
Are you being court ordered or referred to by a case worker? If yes, please provide name and the number of court official or case worker with contacts if possible.
*
Are you currently suicidal and have an active plan?
*
Do you need extra resources?
*
EAC offers a variety of case management services, not limited to but include food pantry, emergency shelter, medical referrals, etc.
What is your availability? Please include days and times.
*
Are you open to telehealth, face to face, or both?
Face to face only
Telehealth only
Both
Date of intake
*
MM
DD
YYYY
