Gretchen Sparacino, M.A., LPC
Confidential Intake Information
I. IDENTIFYING INFORMATION
Last Name
First Name
Local Address (number and street)
Local Phone Number
City
Cell Phone Number
MI
Preferred name (if different)
State
Zip
Work Phone Number
Email Address
Check above box for number at which we can contact you or leave a message. We will not identify ourselves or state why we are calling.
Birth Date ( M/D/Y)
Male
Marital Status: Single
Married
Living
Age
Female
Together
Separated Divorced
Widowed
Disability Type None
Physical
Learning
(Optional)
Behavioral Hearing
Visual
Other
Contact in case of Emergency
Name :
Phone:
Relationship:
Name of Health Insurance Company
Other MD or therapist who is treating you:
Name:
Phone:
Profession:
II. Medical Information:
Do you have any medical problems? No Yes If yes please describe:
Are you currently taking prescribed, over-the-counter, or herbal medication? No Yes If yes, which ones?
Do you use alcohol/drugs now? No Yes If yes what kinds?
How much daily?
How much weekly?
Have you ever had previous psychological counseling? No Yes
If yes, when?
With whom?
For how long?
Have you ever been hospitalized for suicide attempt, drug or
alcohol problems, or an emotional/behavioral problem?
Yes
No
If yes, where?
For how long?
When?
III. SERVICES SOUGHT
Please briefly describe why you are seeking services:
As a result of therapy, what do you most want to accomplish, i.e., resolve, change, discover?
How did you find out about us?
Referral:
Friend
Self
Family
Phone-book
Other:
Please Sign and date:
Signature:
Date:
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I’M FEELING:
(Please check all that apply)
____ agitated
____ anxious
____ angry
____ confused
____ depressed
____ irritable
____ fearful
____ frustrated
____ guilty
____ hopeless
____ “hyper”
____ unhappy
____ lonely
____ numb
____ overwhelmed
____ sad
____ fatigued
I’M HAVING DIFFICULTY:
____ accepting my situation
(Please check all that apply)
____ concentrating
____ controlling my behavior
____ expressing myself clearly ____ making decisions
____ taking care of myself
____ resolving conflict
____ I’m crying a lot
____ controlling my temper
____ relaxing
____ trusting
____ I’m worrying a lot
____ I don’t have enough support (friends, family, etc.)
____ I have panic attacks or phobias
____ I spend too much time on the computer or Internet
____ I don’t feel well most of the time
I’M HAVING:
(Please check all that apply)
____ relationship concerns
____ family problems
____ concerns about my job or work situation
____ financial or economic problems
____ legal problems
____ educational problems
____ health problems or concerns (specify) _________________________________
____ sleep problems:
____difficulty falling asleep
____ recent change in my appetite
____ difficulty staying asleep
____ concerns about my weight or appearance
____ concerns about my sexuality or sexual functioning
____ concerns about my own drug or alcohol use
____ thoughts about harming myself
____ difficulty waking up
____ concerns about my memory or mental functioning
____ concerns about a family member’s drug or alcohol use
____ thoughts about hurting someone else
____ concerns for my safety
MY CURRENT CONCERNS ARE CAUSING ME:
____ mild distress
____ moderate distress
____ serious distress
____ severe distress
I HAVE: (Please check all that apply)
____ had a traumatic experience in my life
____ been arrested (when, for?) ________________________
____ had experience of abuse:
____ sexual
____ physical
____ emotional
OTHER INFORMATION THAT IS IMPORTANT:
_________________________________________________________________________________
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