COUNSELING CLIENT INTAKE FORM TEMPLATE

COMPANY NAME	YOUR LOGO
ADDRESS LINE 1
ADDRESS LINE 2
CITY / STATE / ZIP
PHONE
WEB ADDRESS
DATE	ADMINISTRATOR
IS THIS A PREVIOUS PATIENT?	REFERRED BY
PATIENT ONBOARD INFORMATION
NAME
CELL PHONE	HOME ADDRESS
ALT. PHONE
EMAIL
SOCIAL SECURITY NUMBER	WORK ADDRESS
DATE OF BIRTH
EMERGENCY CONTACT
NAME OF CONTACT	RELATIONSHIP TO CLIENT
MAIN PHONE #	ALT. PHONE #
INSURANCE INFORMATION
NAME OF CARRIER	INSURED’S DATE OF BIRTH
NAME OF INSURED	GROUP NUMBER
SUBSCRIBER ID	SIGNATURE
PAYMENT INFORMATION
PAYMENT TO	PAYMENT DATE
RECEIPT NUMBER	AMOUNT PAID
PAYMENT METHOD
RECEIVED FROM	RECEIVED BY
ACCOUNT INFO	PAYMENT PERIOD
ACCT BALANCE	THIS PAYMENT	BALANCE DUE	FROM
THROUGH
PAYMENT FOR
HEALTH INFORMATION Describe the reason for the initial visit.
HOW OFTEN DO YOU EXERCISE?	WHAT PRESCIRTIONS ARE YOU TAKING?
DO YOU HAVE ANY ALLERGIES?	HOW WOULD YOU RATE YOUR SLEEPING HABITS?
Describe your physical health in general.
Please circle any of the following conditions you’ve had a health issue with.
anemia chronic back pain cancer convulsions seizures migraines osteoporosis	arthritis bladder trouble chest pain high blood pressure kidney trouble heart trouble	anxiety poor circulation sinus trouble asthma indigestion dermatitis epilepsy	broken bone measles hepatitis tuberculosis neck pain diabetes artificial joints	_______________ _______________ _______________ _______________ _______________ _______________	_______________ _______________ _______________ _______________ _______________ _______________
Please elaborate on any conditions circled above.
Describe your mental health in general.
Please circle any of the following conditions you've had a health issue with.
anxiety depression anger concentration phobias communication drugs/alcohol	eating disorders parents children sleeping child abuse sex abuse nightmares	financial problems head injuries nausea attention trust in others worry self-inflicted pain	_______________ _______________ _______________ _______________ _______________ _______________	_______________ _______________ _______________ _______________ _______________ _______________
Please elaborate on any conditions circled above.

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