CVBCC Intake Form

*Not Licensed Professional Counselors

Please complete accurately and submit when finished.
Name

First NameLast Name
Birth Date

MonthDayYear
Spouse's Name

First NameLast Name
Spouse's Birth Date

MonthDayYear
Date
How Long Have You Been Married?
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Date
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Date
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Date
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Date
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Date
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Number*

Area CodePhone Number
Phone Number*

Area CodePhone Number
Is it ok to leave a message?

YesNo
Is it ok to leave a message with a family member?

YesNo
Is it ok to text your mobile number?

YesNo
E-mail
In case of emergency, who may we contact?

First NameLast Name
Emergency contact's phone number?

Area CodePhone Number
Counseling History
Have you or your family ever received counseling for any reason?

YesNo
When?
Reason for counseling?
Why are you seeking counseling now?
How long have you been experiencing this difficulty?
Are you currently working with any other Counselor or Psychiatrist?

YesNo
For what reason and how long?
Name of counselor / agency?
Family History
Briefly describe yourself.
Briefly describe your spouse.
Identify and describe your primary female caregiver as you remember during your life at home. List some of her characteristics as a person.
Identify and describe your primary male caregiver as you remember him during your life at home. List some of his characteristics as a person
How did your parents or caregivers get along with each other while you were in the home.
Describe any significant problems between you and your brothers and sisters.
List any relatives with a history of emotional and mental disorder or suicide (include diagnosis and treatment if known).
List relatives with a history of alcoholism or excessive alcohol or drug use:
List any significant past trauma experienced by you or those close to you (i.e. death, divorce, sickness, crime, etc.)
Religious History
In what religious faith were you raised?
Present church affiliation or name of church you attend:
Have you accepted Jesus as your Lord and Savior?

YesNoUnsure
If yes, when and/or where did you accept Him?
Have your religious experiences and training helped or hurt your ability to deal with your struggles?
How often do you read your Bible?

DailySeveral times per weekOnce per weekOnce per monthNever
Do you have a regular time to pray?

YesNo
Have you had any unusual "religious experiences?"

YesNo
If yes, explain:
Check any losses you have experienced:

Death of spouseDeath of a childDeath of fatherDeath of motherDeath of sisterDeath of brotherDeath of grandmotherDeath of grandfatherDeath of aunt or uncleSuicideMiscarriageAbortionAdoptionInfertilityBankruptcyHomelessnessJob LossDivorceOther
Check any concerns or issues you have now or in the past:

Physical AbuseEmotional AbuseVerbal AbuseSexual AbuseAlcoholAcademic IssuesAddictionAnger / RageAnxietyAttention deficient hyperactivity disorderBinge eatingCareerCo-dependencyCommunicationCutting or self-injuryDepressionDrugsPrescription drugsExcessive dieting or exercise, purgingFearGriefGender identityLonelinessMood swingsNegative or troubling feelings about church or GodParent-child communicationPeer pressurePornographyProcrastinationSelf-hatredStressSuicidal thoughtsSuicidal attemptSuicidal threatShoppingWorking too much
General Information
Physician:

First NameLast Name
City
Date last seen:

MonthDayYear
Reason for last appointment:
Ongoing medical concerns:
Allergies
Medications:
Legal Information
Current legal issues:
Previous legal issues:
Charges:
Serving probation?

YesNo
Court district:
Education Information
Highest grade achieved:
Name of college or vocational school:
Year of Graduation?
Military dates of service:
Branch:
Rank:
Type of discharge:
How was your relationship with your peers?
How was your relationship with your supervisors?
Work History
Are you satisfied with your present occupation?

YesNo
What is your current occupation and how long have you been with your present employer?
Are you satisfied with your present income?

YesNo
Daily Routine
How is your appetite?
Any changes in the last 6 months?
Are you experiencing weight gain or loss?
How well do you sleep?
Any changes in the last 6 months?
Do you fall asleep ok?

YesNoMost of the time
Describe your exercise habits:
List any other concerns the Counselor will need to know:
How did you hear about the Center?
**Someone will contact you soon for an appointment.
Should be Empty:

*Not Licensed Professional Counselors

Counseling History

Family History

Religious History

General Information

Legal Information

Education Information

Work History

Daily Routine