Adult Intake Form – E-Carrington

Adult Intake

Office Hours

By Appointment Only

*Times are subject to change. Please contact our office with your scheduling questions.

PERSONAL INFORMATION

Name

Email Address

Gender

Male Female

Height

Weight

SS#

Age

Date of Birth

Address

City

State

Zip

Home Phone

Business Phone

Cell Phone

EMERGENCY INFORMATION

Name

Relionship to you

Home Phone

Business Phone

Cell Phone

EMPLOYMENT INFORMATION

Employer

Occupation/Title

Employer Information Address

City

State

Zip

Employer Information Phone

Hours per week

Years at job

EDUCATION

Highest level of education completed

Degrees held

Other

Cultural heritage

Do you regularly attend a church, synagogue or other religious institution?

Yes No

Member?

Yes No

Name of church/institution

Name of pastor

RELATIONAL INFORMATION

If engaged, married, divorced or widowed, how long have you been so?

Number of previous marriages for you?

For your current spouse?

Name of spouse

Spouse’s age

Spouse’s Occupation

🗨 Description of your spouse's characteristics

CHILDREN INFORMATION

Please list your children, including step, adopted and foster children

#1

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

#2

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

#3

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

#4

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

#5

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

#6

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Living with whom?

FAMILY OF ORIGIN

Please list your mother, father, brothers, sisters, stepfamily and/or relatives who had a significant effect upon your life (positive or negative).

#1

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

#2

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

#3

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

#4

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

#5

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

#6

Name

Sex

Age

If deceased – Year of Death

Relationship to you

Describe him/her

Please describe the kind of family you grew up in

COUNSELING HISTORY

If you have had any previous counseling, psychiatric treatment, substance abuse treatment, or residential/in-patient care, please list the name of the therapists and/or programs Please include Name of Therapist/Program, Issues Addressed, and Dates in Treatment

Treatment

Has anyone in your family ever been treated or hospitalized for substance abuse, mental health issues, or psychiatric conditions?

Yes No

If yes, please describe

Have any of your family or friends ever attempted or committed suicide?

Yes No

If yes, who and when

MEDICAL HISTORY

Name and Town of Current Physician

Date and outcome of last physical exam

Please list any conditions, illnesses or surgeries that might be relevant to your reason for seeking counseling

Please list current medications you are taking even if use is seldom or as needed Please include Name of Medication, Dosage, and Reason for taking medication

Current Medications

PRESENT ISSUES AND GOALS

Select any of the flowing symptoms or problems that you are currently or have recently experienced

Please check on the scale below to indicate how distressing your problems are to you

Very minimal distress Moderate distress Very extreme distress

Are you currently experiencing any suicidal thoughts?

Yes No

Have you experienced suicidal thoughts or attempted suicide in the past?

Yes No

Are you currently experiencing any violent or homicidal thoughts?

Yes No

Please describe thoughts

REFERRAL INFORMATION

How did you find us (referred by doctor, friend, family, internet, EAP or other)?