Intake Form - Beth McCain | Wellness Counseling Center

PERSONAL INFORMATION

Name*

First Last

Age*

Date of Birth*

Address*

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

Cell Phone*

Voice Mail OK?*

Yes
No

Text Message OK?*

Yes
No

Email*

EMPLOYMENT / EDUCATION

Your current employer/business or school:*

Your occupation / title:*

How long?:

Do you have children?*

Yes
No

If yes, please list names and ages below:

EMERGENCY CONTACT

Name*

First Last

Phone*

Relationship:*

RELATIONSHIP STATUS

Your current relationship status:*

PREVIOUS THERAPY

Have you been in therapy before?*

Yes
No

If yes, with whom?

For how long?

MEDICAL INFORMATION

Physician's Name*

First Last

Physician's Phone

List any medical problems you may have:

List all prescription medications you are taking:

List OTC and other products:

LEISURE / SELF-CARE

How do you use your free time?*

When you are on the internet, where do you typically spend your time?*

Do you use alcohol?*

Yes
No

How much?

How often?

GOALS AND OBJECTIVES

What are current issues/problems you'd like to address in therapy?*

What are your goals for the outcome of our work together?*

Please complete this sentence: I will be finished with therapy and consider it successful when...*

Consent*

I agree these statements are true.