Adult Intake Form Adult Intake Form HiddenDate MM slash DD slash YYYY Name* First Middle Last Date of Birth* MM slash DD slash YYYY Age*Birth Sex*MaleFemaleSelf-Reported Gender:MaleFemaleAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code May we send mail here?*YesNoHome PhoneOK to leave message?YesNoWork PhoneOK to leave message?YesNoCell PhoneOK to leave message?YesNoEmail* OK to send email here?YesNoPerson to call in case of emergency* Their Phone Number*Current Relationship Status*SingleDatingCommitted RelationshipMarriedDivorcedSeparatedLive TogetherWidowedSexual Orientation*HeterosexualGayLesbianBisexualTranssexualOther / Prefer not to answerPrimary Cultural Background with which you identify*African American/BlackAsianCaucasian/WhiteBiracialHispanic/LatinoOther / Prefer not to answerReferred by May I thank the professional who referred?YesNoWe are always grateful for referrals.Their contact information Employment InformationEmployer Length of timeOccupation Number hours worked/weekEducationHighest Grade/Degree completed Currently in School?YesNoType of Degree Relationship InformationPast and Present marriages/significant intimate relationshipsFirst Name Years TogetherNature of RelationshipsDistantFriendlyAbusiveHostileLovingFirst Name Years TogetherNature of RelationshipsDistantFriendlyAbusiveHostileLovingFirst Name Years TogetherNature of RelationshipsDistantFriendlyAbusiveHostileLovingFirst Name Years TogetherNature of RelationshipsDistantFriendlyAbusiveHostileLovingDevelopmental Information:First Name Age Brief Description of Your Relationship with the Child First Name Age Brief Description of Your Relationship with the Child First Name Age Brief Description of Your Relationship with the Child First Name Age Brief Description of Your Relationship with the Child Please identify any family members with mental health, substance abuse or violence issuesChemical Use: Do you currently use any recreational drugs, tobacco, vape, or drink alcohol?YesNoAny past substance abuse: Medical: Primary Physician Name: Phone: Physician Address: Are you currently receiving medical treatment:YesNoIf yes, please specify:List any illnesses, surgeries, hospitalizations, or traumas related to medical treatment you have hadMay I contact your doctor to consult with him/her about your treatment?YesNoCurrent Medications/dosages:Religious/Spiritual Issues: Are religious/spiritual issues important to you?YesNoWould you like faith to be a part of your counseling process?YesNoDo you have a personal support system?YesNo(If yes, who?)Legal History: Is your participation in therapy today related to any legal matter? (ie- accident, injury, criminal activity, probation condition, court order, or divorce)YesNoIf yes, please explain:Suicide Assessment: Have you ever attempted suicide?YesNo(how long ago did this occur and how many times?)Do you have any current thoughts of ending your life?YesNoDo you have a plan? (please explain)Social/Personal/Leisure: What activities or social involvement help you to feel joy or pleasure in life?Insurance Information: Name of Healthcare Insurance CompanyName of Insured Policy Holder: Member Identification Number: Please understand that utilizing health insurance benefits requires this provider to submit personal health information to your insurance company, specifically a procedural code indicating the type of treatment and length of time of the appointment. Additional information supplied to the insurance company is a diagnostic code for the purpose of reimbursement for services. Information obtained during the clinical process will not be released without your written consent unless court-ordered. Confidentiality may also be waived in situations where a client is in danger to self or others, or there are indications of child or elder abuse/neglect. Terms of Service: I understand that it is customary to pay for services when rendered. I accept full responsibility for payment of any balance incurred for services. I further understand that without a 24-hour notice of intention to cancel, I will be charged the full administrative fee for services. Your therapist is available after regular business hours and on weekends by phone. However, an immediate response to your call cannot be guaranteed. Phone consultation after hours in excess of 10 minutes will be billed in accordance with your regular hourly fee. Please understand that in case of emergency, you may need to contact 911 or a local mental health facility or hospital. I understand that my participation is purely voluntary and that I may withdraw whenever I wish. All records are the property of Linda Mesing Cook, M..S., LMHC. I have read and understand all of the information on this form. I give consent for treatment of myself or the client indicated below. I understand that I may discuss with my therapist all aspects of my treatment and any issues on this form.Client printed name: Client Signature:HiddenTodays Date Month Day Year