New Client Clinical Intake

New Client Intake

Services Requested

Therapeutic Coaching

Counseling

Client's Issues/Concerns (check all applicable)

Client Demographic Information

* Indicates required field

10a. Employment Status *

Self-Employed Part-Time Employment Full-time Employment "Under-the-Table" work

10c. If client is a student please include client's current grade level and name of school *

Mental & Physical Health History

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. Include current significant stressors such as financial problems, legal issues, troubles with hygiene, staying neat, staying tidy and organized,, exhibits of cognitive distortions (etc) *

Who referred Client? *

Is therapy/counseling mandated? *

Client's 1st goal - Develop insight and gain skills to manage problems with *

Client's 2nd goal - Develop coping skills to manage problems with *

Name of Person Completing Intake *

First

Last

Date *