Adult Client Intake Form Step 1 of 10 - Personal Info 10% Personal InformationName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Email Date of Birth DD slash MM slash YYYY Race/Ethnicity Asian Portuguese Black or African Descent Hispanic or Latino Native Hawaiian or Other Pacific Islander White Contact InformationCell PhoneHome PhoneWork PhoneAddress Street Address Address Line 2 ZIP / Postal Code BermudaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name First Last Emergency Contact Relationship Emergency Contact Number EmploymentEmployed* Yes No employed type Part Time Full Time Occupation Education Some High School High School Diploma GED Some College/University College/University Degree Technical Qualification College Degree Qualification General Physical & Mental Health InformationName of primary care physician: Are you currently on any medication?* Yes No Medications* Have you received therapy before?* Yes No When Therapist Have you or a family member ever been hospitalized for mental or emotional illness?* Yes No When Reason Substance UseDo you use Alcohol? Yes No How often? Every day Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month How many drinks at a time?Please enter a number greater than or equal to 1.Do you use Marijuanna? Yes No How often? Every day Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month How much do you use? Do you use other drugs? Yes No How often? Every day Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month What drugs do you use? Have you received any previous treatment for substance use?* Yes No Where did you go? Insurance InformationDo you have insurance?* Yes No Insurance Provider* BF&M Colonial Argus GEHI Name of insured First Last HiddenPolicy/Group Number* Reason for seeking counselling:What are your 2 most important goals for therapy? IssuesRate the issues that are important to you from Mild to Severe.Rate all the issues that apply to you from mild to severeNoneMildModerateSevereMarriagePre-MaritalBeing SingleSexual IssuesFamilyChildrenParentsIn-LawsDivorce/SeparationChild CustodyDisabledWork/CareerEducationMoney/FinancesAging/DependencyWeight ControlAlcohol/DrugsGrief/LossOther AddictionsDepressionFear/AnxietyAnger ControlLonelinessMood SwingsGod/FaithTrauma/Past HurtsChurch/MinistryCo-DependencyIntimacyCommunicationSelf-EsteemStress ControlRate all the issues that apply to you from mild to severe Family InformationMarital Status Single Dating Relationship Engaged Married Separated Divorced Widowed Children? Yes No How many and how old? What is your relationship like with the following:CloseSomewhat closeDistantConflictedMotherFatherSiblingsFriendsAreas of work please check all that apply to you Anger Withdrawn Peer Problems Behavioural Problems Self-Blame Unhelpful Thoughts Impulsiveness Aggression Anxiety Gang Involvement Abandonment Isolation Depression Mood Swings Never Tired Self-Harm Past Trauma Harming Others Crisis InformationAny current suicideal thoughts, feelings or actions? Yes No DetailsAny current homicidal or violent thoughts, feelings or anger-control problems? Yes No DetailsAny hospitalizations, or imprisonments for suicidal or assault behavior? Yes No DetailsAny current threats of significant loss or harm (illness, divorce, custody, job loss, etc.)? Yes No DetailsIs there anything else you would like me to know?How did you hear about us?Privacy PolicyPRIVACY POLICY HEREConsent I agree to the privacy policy.PhoneThis field is for validation purposes and should be left unchanged.
