Intake | 1949

The Intake form gives me basic information about you. If there is anything you want to leave blank, please do so. If it is something I need, I'll ask. You can get a printable copy here.

Jim Colbert, M.Ed., LPC

Client Demographic & Intake Information

3008 Dawn Dr., Suite 101 Georgetown, Texas 78628 Email: colbertjmc@gmail.com

Phone 512-569-7573 Fax (512) 819-0256 Webpage: www.jcolbertlpc.com

Demographic Information:

Client’s Name: __________________________________ Client Social Sec # :________________________

DOB: __________________ Age:________ Sex: _________ Marital Status: ____________________

Client Status: _______ Employed _______F/T Student _______P/T Student _______ Work at Home

Employer:________________________________________JobTitle:__________________________

Client Address:_________________________________________ City:____________________________________

State: ____________ Zip: ____________________Home Phone: _____________________

Other Phone: _____________________Is it okay to leave messages? ________ Email: ____________________________

Which do you prefer for appointment reminder contacts? __email __home __cell ___ no reminder contacts

Primary Care Doctor: __________________________________ Phone: ____________________________

Current medications: _________________________________________________________________________________

In Case of Emergency Notify: _______________________________________________________________

Phone: __________________________________ Relationship:__________________________________

Educational/Occupational: Adults

Highest Grade Completed; ______ College: ________________ Graduate School: _____________________

Are you currently employed? ____ With __________________________________________ How long? ________________

Like/Dislike/Secure: ________________ Do you commute? _______

Describe your drive _____________________________________________________________________

Educational/Occupational: Teens and Children:

Current Grade: ____ School: _____________________________________ Resource, LD, ED or Special Ed._______

Ever failed a grade? Y N Which and Why: ________________________________ Favorite class:_______________________

Worst Class: ______________________Do you skip? Y N Some

Extracurricular Activities: _________________________________________________________________________

Problems at school: ________________________________________________________________________________

Family Structure, Relationship and Social Roles:

Married: ___ Divorced: ___ Separated: ___ Single: ___ Dating: ___ How long? ____

Name of Adult’s Spouse or Significant Other: _____________________________________________

Names and ages of Parents, children, siblings living in the home: _________________________________________

___________________________________________________________________________________________

Additional Support or family in the home: __________________________________________________________

Describe friends and activities that you enjoy with them _______________________________________________

___________________________________________________________________________________________

Are you (the client) outgoing, active, shy, withdrawn or it depends: ________________________________________

Do You attend Religious services? _________________________ Which Denomination? _____________________

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Significant Life Events:

Birth ____ Death ____ Moving ____ Miscarriage/fertility problems _____ Divorce ____ Change of Job ___

Behavior ___ Sleep Patterns ___ Friends ___ Appearance ___ Other _____________________________________________

Significant illness of you or someone close? ___________________ Victim of a crime ______________________________

Arrest ___ Loss of relationship __________________________________ Runaway ___

Traumatic event (car wreck, natural disaster, military) _____________________________________________________________

History of Physical or sexual abuse or neglect? ___________________________________________________________________

History of emotional/verbal abuse or neglect? ____________________________________________________________________

Emotional/Psychological/Mental Health:

Have you ever participated in therapy before? When? ______________________________________________________________

Any family history of depression, ADD/ADHD, schizophrenia, anxiety? Who?_________________________________________

_______________________________________________________________________________________________________

Change in appetite? Describe _______________________________________________________________________________

How many hours a night do you sleep? From/To _________________________________________________________________

Trouble falling asleep? __________________ Awakenings? ___________________ Dreams/nightmares? ___________________

Trouble staying focused, concentrating, staying on task? ___________ Thoughts racing; jumping from topic to topic?___________

Feelings of paranoia, being watched or followed? ________ Hallucinations? _________ Delusions? ______________

Grandiose/Manic? _____________ Rituals? ______________ Flashbacks? ____________ Self injury? ____________________

Preoccupations with behavior numbers or thoughts? ___________ Excessive worry/anxiety ___________

Sadness/Loneliness? ____________ Feelings of wanting to harm yourself or others? ________________________________

Feelings of wanting to die? When _____________________________________________________________________________

Suicide Attempt(s)? When? __________________________________________________________________________________

How do you react when you are:

Angry ___________________________________________________________________________________________________

Happy ___________________________________________________________________________________________________

Sad ______________________________________________________________________________________________________

What has brought you here? What symptoms, feelings, thoughts, etc, prompted you to seek counseling?

_________________________________________________________________________________________________________

What would you like to accomplish in therapy? __________________________________________________________________

_________________________________________________________________________________________________________

Is there anything else you would like for me to know? _____________________________________________________________

_________________________________________________________________________________________________________

Therapists Notes:

_______________ ___________________________________________________________

Date Jim Colbert, M.Ed., LPC

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