Intake Form CARE Counseling Clinic New Client Intake Form Step 1 of 5 20% Except in cases of abuse to a minor or immediate danger to yourself/others, all information provided will be kept strictly confidential and released only in accordance with necessary professional ethics and state/federal law.Date* MM slash DD slash YYYY Who can we thank for referring you to CARE Counseling Clinic? DemographicsClient's Name* First Last Sex* Male Female Birth Date* MM slash DD slash YYYY Email Address* Street Address City State / Province / Region ZIP / Postal Code Cell PhoneHome PhoneAppointment Reminder OptionsWould you like appointment reminders? If so, please choose an option below. Text Message Reminder 24 hours prior to appointment (leave preferred phone number below) Phone call reminder 24 hours prior to appointment (leave preferred phone number below) Preferred Appointment Reminder Phone NumberService Type and AttendeesAre you seeking (check all that apply):* Individual Counseling Couples Counseling Family Counseling Others who will attend sessions (Click "+" to add more):NameDOBRelationship Click "+" to add more Clients under age 18If client is under age 18, please complete the following (click "+" to add more fields):NameMother or FatherDOBPhone #Employer Relationship of Parents: Married Separated Divorced Emergency ContactName:* First Last Phone:*Relationship to client:* Insurance InformationInsurance Company Name:* Business phone number (on card):*ID#:* Group#:* Upload a copy (front & back) of your Insurance card Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB, Max. files: 2. Policy Holder InformationName:* First Last Social Security #* DOB* MM slash DD slash YYYY Deductible Co-Pay Is pre-authorization required? Yes No If yes, please obtain and provide authorization number Secondary Insurance InformationName Social Security # DOB MM slash DD slash YYYY Deductible Co-Pay Is pre-authorization required? Yes No If yes, please obtain. Counseling InformationWhat are you seeking assistance with?*History of Presenting symptoms (describe when symptoms began, previous treatment, and how you and or family are impacted):*Have you had previous mental health inpatient hospitalizations?* Yes No If yes, please list when and where:Do you have family members with a history of mental health or addiction issues?* Yes No If yes, please list relationship and type of issue:Have you made previous suicide attempts?* Yes No If yes, please list how and when:Has anyone close to you attempted or committed suicide?* Yes No If yes, please list who and when:Medical HistoryDo you have past or present medical complications/surgeries (migraines, diabetes, physical pain)*Do you have allergies?* Yes No If yes, please list type of allergy:Please list family history of medical issues.*Name of Primary Care Provider* Name of Clinic Current MedicationsPlease list your current medications - (click "+" to add more):MedicationPrescribed for?DosageHow many times per day? Name of Psychotropic Medication Provider: SymptomsPlease select all that apply.* Low/Depressed Mood Crying Without Reason Isolating Feelings of worthlessness Loss of interest or thoughts of suicide Unwanted thoughts Weight loss/gain Sleep issues Irritability/Agitation Social Withdrawal Low Motivation Fatigue/Loss of Energy Restless Stress Daily or Chronic Pain Medical Complication(s) Memory Problems Difficulty Concentrating Losing or Misplacing Items Hyperactive/Fidgety Poor Focus and Concentration Decreased need for sleep Mood Swings Daily Anxiety Panic Attacks Excessive Worry Social Anxiety Fears/Phobias Obsessive Thoughts or Behaviors Compulsive Thoughts or Behaviors Binge Eating/Overeating Restricting Food Purging/Vomiting Poor Body Image Low Self-Esteem Experienced Trauma past or present FeelingMentally Disconnected Nightmares/Flashbacks Easily Startled/Jumpy Mistrusting of Others Uncontrolled Rage/Anger Aggressive Behavior Anger Difficulty with Forming and Maintaining Relationships Self-Sabotaging Behaviors Relationship Sabotaging Behaviors Fears of Abandonment Manic Behavior Racing Thoughts If yes to any of the above, please describe:*Do you have thoughts of suicide?* Yes No If yes, are you having: Ideations Plan Intention Self Harm or Thoughts of self harm?* Yes No If yes, please describe self-harming behaviors and/or thoughts:Hallucinations?* Yes No If yes, please describe:Delusions?* Yes No If yes, please describe:Other issues (please select all that apply): School related issues Legal Issues Current relationship issues Family issues Work related issues Financial issues Sexual issues If yes, please describe:Drug and/or Alcohol UseAre alcohol or drugs a problem for you or others in your life? Yes No Check those that apply to you: Alcohol Use Drug Use How often do you use? When was your last use?Type of drugs or alcohol you use?Please list any previous drug or alcohol treatment including inpatient and outpatient, time in treatment, etc. | Click (+) to add more fieldsDrug/Alcohol?Inpatient/Outpatient?Time in Treatment? Do you have any family members with past or present drug or alcohol issues? Yes No If yes, please describe: Trauma HistoryHave you witnessed or experienced trauma?* Yes No If yes, please briefly describe:Other QuestionsAre you currently: Married Single Separated Divorced Widowed Years in current relationship? How would you describe this relationship?Do you have children? Yes No Please list first names and ages and if they currently live at home (click "+" to add more):NameAgeAt Home? Are you currently employed?* Yes No What is your occupation? What are your current coping strategies?*What are your strengths?*What is your recovery goal?*Describe your social and family support system:*Please describe any religious or cultural considerations:Is there anything else you would like to share?Terms of Service*Please read our attached terms below and click to acknowledge that you have read and agree to our terms. Thank you.1. Acknowledgement and Consent to Use Electronic Communication 2. Counseling Disclosure 3. Fee Agreement and Contract For Angie Sherwood, LCSW | Jessica Crocker | Spring Baxter 4. No Show and Late Cancellation Policy 5. Notice of Privacy Practices I agree to the Terms of Service When clicking submit, the information you provided on the intake form will be transmitted securely through HIPAA compliant methods.EmailThis field is for validation purposes and should be left unchanged. Δ