Counseling Intake Form - Peoples Church

What kind of counseling services do you require? *

General Information

Please provide the following information and answer all the questions to the best of your ability. All information you provide on this form is protected as confidential information.

Is it safe for us to send you an email at this address? *

Yes

No

Phone number *

Is it safe for us to leave you a voicemail at this number? *

Yes

No

How old are you? *

Name of Parent/Guardian if under 18 years?

What is your gender? *

Male

Female

What is your relationship status? *

How long have you attended Peoples Church? *

I do not attend Peoples Church

Less than 1 Year

1-5 Years

6-10 Years

10+ Years

Counseling Information

Information on your personal, general and mental health information. Please provide the following information and answer the questions to the best of your ability. All information you provide on this form is
protected as confidential information.

Have you previously received any type of mental health services (psychotherapy, psychiatry, etc.)? *

Yes

No

Are you currently taking prescription medications? *

Yes

No

Have you ever been prescribed psychiatric medications including anti-psychotics? *

Yes

No

How would you rate your current physical health? *

min: 1 / max: 5

Excellent 1 | 2 | 3 | 4 | 5 | Poor

What is the name of your Primary Care Physician (PCP)? *

When is the last time you saw your PCP? *

Are you currently experiencing any chronic pain? If yes, please describe.

How would you rate your current sleeping habits? *

min: 1 / max: 5

Excellent 1 | 2 | 3 | 4 | 5 | Poor

How many days a week do you generally exercise? *

Please list any difficulties you experience with your appetite or eating patterns.

Are you experiencing anxiety, panic attacks, or phobias? If yes, for approximately how long?

Are you experiencing overwhelming sadness, grief, or depression? If yes, for approximately how long?

Are you experiencing depression, lack of energy, or any social isolation? If yes, for approximately how long?

Please select any mental health issues that run in your family. *

Alcohol/Substance Abuse

Attention Deficit Hyperactivity Disorder or Attention Deficit Disorder (ADHD or ADD)

Bipolar Disorder (BD)

Borderline Personality Disorder (BPD)

Depression

Domestic Violence

Dissociative Identity Disorder (DID)

Eating Disorders: Anorexia/Bulimia (AN or BN)

Emotional Abuse

General Anxiety Disorder (GAD)

Physical Abuse

Post Traumatic Stress Disorder (PTSD)

Obsessive Compulsive Disorders

Schizophrenia

Sexual Abuse

Suicide or Suicidality

Other

No Mental Health Issues

If a counselor determines that group counseling would be better for you, would you be open to that suggestion? *

Yes

No

Do you drink alcohol more than once a week? *

Yes

No

Sometimes

Do you engage with recreational drug use? *

Yes

No

What significant life changes or stressful events have you experienced recently? *

What would you like to accomplish out of your time in counseling? *

Are you requesting couples counseling? *

Yes

No

Do you have children? *

Yes

No