New Client Clinical Intake

Client's Full Name *

First

Last

Name of Parent/Guardian (if client is minor child) *

First

Last

Client's Date of Birth (MM/DD/YYYY) *

If client is a student please include client's current grade level and name of school *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Client's Race/Ethnicity Identification *

Client's Relationship Status *

Insurance Company *

Full Name of Primary Insured (if other than client) *

First

Last

Insurance ID# *

Date of Birth of Primary Insured (MM/DD/YYYY) *

Address of Primary Insured (if different than client's) *

Line 1

Line 2

City

State

Zip Code

Country

Please describe client's current living situation *

Please indicate the client's current household situation *

Has client ever attempted suicide? *

If yes, please explain (include dates) *

Does client currently have suicidal thoughts? *

If yes, please explain *

Has client ever seriously harmed or hurt others? *

If yes, please explain (include dates) *

Does client currently have thoughts or urges to harm or hurt others? *

If yes, please explain *

Has client ever been hospitalized for a psychiatric issue *

If yes, please explain (include dates and names of hospitals) *

Has client seen mental health providers before? *

If yes, please list past mental health treatment providers and dates of service (do not include hospitalizations) *

Is client currently under the care of a mental health provider? *

If yes, please list name and contact data for each provider *

Does client have a primary care doctor or family medicine doctor? *

If yes, please list name and contact data for each provider *

Please list all current prescription medications and name of prescriber *

Please list current mental health and physical health diagnoses, dates of diagnosis, and names of providers who gave diagnosis *

Does client consume alcohol? *

If yes, describe age of first use and current amount and frequency *

Does client use recreational drugs? *

If yes, describe age of first use and current amount and frequency *

Does client use cigarettes/nicotine? *

If yes, describe age of first use and current amount and frequency *

Additional Comments/Notes (include current significant stressors such as financial problems, legal issues, troubles with ADLs, exhibits of cognitive distortions (etc) *

Who referred Client? *

Primary Diagnosis *

Secondary Diagnosis (if applicable) *

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New Client Clinical Intake

New Client Clinical Intake