CVBCC Intake Form

*Not Licensed Professional Counselors

Please complete accurately and submit when finished.
Name

First Name Last Name
Birth Date

Month Day Year
Spouse's Name

First Name Last Name
Spouse's Birth Date

Month Day Year
Date Date Picker Icon
How Long Have You Been Married?
Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
Date Date Picker Icon
Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
Date Date Picker Icon
Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
Date Date Picker Icon
Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
Date Date Picker Icon
Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
Date Date Picker Icon
Child's Name

First Name Last Name
Child's Birth Date

Month Day Year
Date Date Picker Icon

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mobile Number *

Area Code Phone Number
Phone Number *

Area Code Phone Number
Is it ok to leave a message?

Yes No
Is it ok to leave a message with a family member?

Yes No
Is it ok to text your mobile number?

Yes No
E-mail
In case of emergency, who may we contact?

First Name Last Name
Emergency contact's phone number?

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

Yes No
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?

Yes No
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?

Yes No Unsure
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?

Daily Several times per week Once per week Once per month Never
Do you have a regular time to pray?

Yes No
Have you had any unusual "religious experiences?"

Yes No
If yes, explain:
Check any losses you have experienced:

Death of spouse Death of a child Death of father Death of mother Death of sister Death of brother Death of grandmother Death of grandfather Death of aunt or uncle Suicide Miscarriage Abortion Adoption Infertility Bankruptcy Homelessness Job Loss Divorce Other
Check any concerns or issues you have now or in the past:

Physical Abuse Emotional Abuse Verbal Abuse Sexual Abuse Alcohol Academic Issues Addiction Anger / Rage Anxiety Attention deficient hyperactivity disorder Binge eating Career Co-dependency Communication Cutting or self-injury Depression Drugs Prescription drugs Excessive dieting or exercise, purging Fear Grief Gender identity Loneliness Mood swings Negative or troubling feelings about church or God Parent-child communication Peer pressure Pornography Procrastination Self-hatred Stress Suicidal thoughts Suicidal attempt Suicidal threat Shopping Working too much
General Information
Physician:

First Name Last Name
City
Date last seen:

Month Day Year Date Picker Icon
Reason for last appointment:
Ongoing medical concerns:
Allergies
Medications:
Legal Information
Current legal issues:
Previous legal issues:
Charges:
Serving probation?

Yes No
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?

Yes No
What is your current occupation and how long have you been with your present employer?
Are you satisfied with your present income?

Yes No
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?

Yes No Most 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:

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*Not Licensed Professional Counselors

Counseling History

Family History

Religious History

General Information

Legal Information

Education Information

Work History

Daily Routine