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Intake Assessment Information - Adult

Blue Water Counseling
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
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Social Security Number:
Drivers License Number:
Address & Phone:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
  Message may be left at above phone number?    
  Yes        No   Yes        No   Yes        No
Email:
Emergency Contact:
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Relationship:
Email:
I. ADULT CLIENT
Concerns for which you are seeking assistance
II. FAMILY INFORMATION
A. Marital status
Single   Married   Divorced  
Separated   Cohabitating   Widowed  
Partnered     
B. Race/cultural information
Race
Cultural considerations
LGBTQ Considerations:
C. Family history of mental health or substance abuse problems
Explain
D. Your parents marital status is
Married   Divorced   Separated  
Never married     
Your parents are
Birth parents   Step parents   Adoptive parents  
Father's name
Father's age
If father deceased, date
Father's occupation
Father's highest grade level
Mother's name
Mother's age
If mother deceased, date
Mother's occupation
Mother's highest grade level
E. Your annual family income
Under $30,000   $31,000 - $60,000   $61,000 - $90,000  
$91,000 - $120,000   $121,000 - $150,000   Over $151,000  
F. Language spoken
G. Current family size
H. Your brothers and sisters
  Name Age Occupation Education If deceased, date Relationship
1.
2.
3.
4.
5.
I. Your children
  Name Age Sex Occupation or grade Living with client? Living where Relationship
1.
2.
3.
4.
5.
J. Spouse and/or Other household members
  Name Age Sex Occupation or grade Relationship to client
1.
2.
3.
4.
5.
K. Relationships
1. Who do you live with currently?
2. Who did you grow up with?
3a. Describe your relationship with your parents
3b. Describe your relationship with your siblings
3c. Describe your relationship with your extended family members
3d. Describe your relationship with your spouse/significant other
3e. Describe your relationship with your children
4. List any family members you wish to have involved in treatment and why
III. PHYSICAL DESCRIPTION
A. Height
Weight
Recent gains or losses
B. Other distinguishing features
C. List any physical impairments or disabilities
D. Explain any physical characteristics or body image concerns
IV. EDUCATION
A. Graduated high school
Year
Graduated GED
Year
B. Did not complete school
If yes, last school attended
Grade completed
C. Currently enrolled
If yes, last grade completed
Current grade
D. Post high school education
Explain
E. Years in special education
Special education certification
F. School performance is/was a concern
Explain
G. READING LEVEL:
Good   Fair   Some assistance needed  
V. EMPLOYMENT
A. Currently employed
If yes, indicate
Full time   Part time   Seasonal  
B. Name of employer
C. Position
D. List type of jobs held over last five years
E. Describe your level of satisfaction with your employment/career
VI. SPIRITUAL INFORMATION
A. Spirituality is an area of support or strength
Religion
Catholic   Jewish   Islamic  
Protestant   Other    
Other
B. Is this an area of concern?
If yes, explain
VII. SEXUAL FUNCTIONING
Is this an area of concern?
If yes, explain
VIII. COMMUNITY SERVICES RECEIVED
A. Mental health counseling/substance abuse treatment
Previous counseling where
Previous counseling when
Previous counseling where
Previous counseling when
Previous counseling where
Previous counseling when
Was counseling helpful to you in the past?
If yes, explain
B. Support groups
1. List any support groups you attended in the past or present
2. Was support group attendance helpful?
If yes, explain
IX. SUBSTANCE ABUSE
A. Do you use illegal or unprescribed drugs including alcohol?
If yes, explain which drugs, amount and frequency
B. Do you misuse prescription dugs?
If yes, explain which drugs and how they are misused
C. Do you drink alcohol?
If yes, describe amount and how often per week
D. Is drug or alcohol use an area of concern?
If yes, explain
E. Has anyone ever expressed concern with your use of alcohol or other drugs?
If yes, explain
F. Have you ever been to an Alcoholics Anonymous or Narcotics Anonymous meeting?
G. Have you ever had a legal charge related to alcohol or other drug use?
If yes, explain
H. Do you smoke cigarettes?
If yes, explain time period, amount and frequency
X. SOCIAL LIFE
A. Explain your family's strengths
B. Describe your support system (i.e., family, friends)
C. Describe your recreational interests
D. Describe any relationship problems with friends/coworkers
XI. HEALTH HISTORY
A. Primary physician
Primary physician address
Primary physician phone
Date of last physical exam
B. Pharmacy (include Street, City):
Phone:
C. List all current prescriptions, regularly taken, over the counter meds and supplements
D. Any concerns about medications, including drug allergies?
If yes, explain
E. Health problems
  Status Family History
Allergies
Anorexia
Asthma
Broken Bones
Communicable Diseases
Diabetes
Fainting/Dizzy
Hearing Problems
Heart Disease
High/Low Blood Pressure
High/Low Blood Sugar
Liver Disease, Jaundice
Major Injuries
OB/Gyn Problems
Obesity
Seizures/Epilepsy
Stomach or Intestinal Problems
Thyroid Problems
Ulcer
Vision Problems
High/low blood sugar
Never   Past   Present  
Comments
Assistive Technology Needed:
F. Nutrition generally good?
Explain any special dietary needs/concerns
XII. ABUSE HISTORY
Have you (or your child) experienced or witnessed physical , sexual or emotional abuse or trauma?
If yes, explain
XIII. LEGAL HISTORY
A. Any history of legal charges?
If yes, explain
B. Are you currently on parole?
If yes, explain
C. Is treatment court ordered?
If yes, explain
XIV. ANY OTHER RELEVANT CONCERNS
Please describe
Notes
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