Download Counseling Intake Form

2016
1
Avalon Social Services, Inc.
BCJP Counseling Services Intake
Client Name: ___________________________________ Probation Officer: _________________________________
Date: _____________
Counselor: ___________________________________________ Location:______________
DOB: ______________ Session Start Time: ______________________ Session End Time: ___________________
DOB _________Gender: M F Age: _______
Grade/Education Level: ____ Legal Guardian: _______________
DSM-V Diagnosis: Specifics including Severity
ICD-10 Code(s)_____ _____ ____ _____
Diagnosis:______________________________________________________________________________
______________________________________________________________________________________
__________________________________________________________________________
Presenting Problem History
Reason for Referral: ______________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Legal Involvement/History: ________________________________________________________________________
__________________________ ____________________________________________________________________
______________________________________________________________________________________________
Duration of Symptoms: ___________________________________________________________________________
______________________________________________________________________________________________
History of Present Illness/Problem: __________________________________________________________________
_______________________________________________________________________________________________
Attempts to Resolve Current problem/Situation: ________________________________________________________
_______________________________________________________________________________________________
Additional Family Members to participate in Treatment:
__________________________________________________
Sent to Probation:
Hand Delivered
Faxed
Mailed
Date:
2016
2
Chemical Dependency Issues:
_______________________________________________________________________
_______________________________________________________________________________________________
Psychiatric History
Psychiatric Hospitalizations: _______________________________________________________________________
Past Counseling Experience: _______________________________________________________________________
(Year/Date)
Duration
Family History of Mental Illness/Related Symptoms/Substance Abuse/ Treatment:
 History of physical or sexual abuse: _____________________________________________________
 Depression: ___________________________
 Anxiety/Panic/Phobia: _________________________
 Mania/Bipolar: ________________________
 Delusional/Psychotic: _________________________
 ADHD/Conduct Disorder: _______________
 Mental Retardation: ___________________________
 Learning Disability: ____________________
 Dementia: ___________________________________
Alcohol: ______________________________
 Marijuana: __________________________________
 Cocaine: _____________________________
 Narcotics: ___________________________________
 Hallucinogens: ________________________
 Amphetamines: _______________________________
 Sedatives: ____________________________
 Inhalants: ___________________________________
 Prescription Drugs: _____________________
 Other: ______________________________________
Family/Social/Developmental History
Pregnancy Complications: ________________________________________________________________________
Birth place, Weight, Complications: _________________________________________________________________
Birth Order and Siblings: __________________________________________________________________________
Parental Discipline: ______________________________________________________________________________
Parent’s Marital History: __________________________________________________________________________
______________________________________________________________________________________________
Developmental History/Significant Events: ____________________________________________________________
______________________________________________________________________________________________
Milestones:
Walk: ____________ Talk: __________ Toilet Training: ____________ Other: __________________
Academic History: _______________________________________________________________________________
Ever Suspended: _____________________________ Grades Repeated: ____________________________________
Grades: Elementary: ___________ Middle: ____________ High: ___________ College: ______________________
Current School & District: _________________________________ Teacher: _______________________________
Marital Status:  Single  Married  Significant Other  Divorced  Widowed  Remarried
Sent to Probation:
Hand Delivered
Faxed
Mailed
Date:
2016
3
Relationships/Marriage/Children: ___________________________________________________________________
______________________________________________________________________________________________
Alcohol and Drug Use History (age of onset, amount, frequency, cessation)
 Alcohol
 Cocaine
 Prescription Drugs
 Marijuana
 Sedatives
 Tobacco/Nicotine
 Inhalents
 Amphetamines
 Narcotics
 Other: ________________________________
Comments: _____________________________________________________________________________________
Current family Functioning: ________________________________________________________________________
______________________________________________________________________________________________
Financial Difficulties: _____________________________________________________________________________
Client strengths/Coping Mechanisms/ Support System: __________________________________________________
______________________________________________________________________________________________
Medical History
 Pregnancy/Birth Complications
 Familial Left-Handedness
 Loss of Consciousness
 Head Injury
 Stroke
 Seizures
 Surgeries
 Loss of Coordination
 Fainting/Dizziness
 Hypertension
 Diabetes
 Kidney/Liver Dis.
 Thyroid Problems
 Weakness/Numbing
 Shaking/Tremor
Allergies
 Migrains/Headaches
 Infections
 Toxic Exposure
 Cancer/Radiation
 Blackouts
 Malnutrition
 Hearing Changes
 Developmental Dis.
 Electrical Accidents
Medication
UTI/Impaction
 Neurological Illness
 Memory Changes
 Visual Changes
Abnormal Neuroimaging
 Other
Describe any identified: ___________________________________________________________________________
______________________________________________________________________________________________
Current Medication/Recent Changes in Medication: _____________________________________________________
Additional Information: __________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
____________________________________________
Counselor
Sent to Probation:
Hand Delivered
Faxed
_____________________________________
Date
Mailed
Date:
2016
Sent to Probation:
4
Hand Delivered
Faxed
Mailed
Date: