Initial Therapy Intake Form
Life Line Counselors LLC

 

 
Name  _____________________________________________________                                                                                       
Age _______            Birth date     _____/_____/_____                      
Address:____________________________________________________ 
Email: ____________________________                                                
City:_______________     State: _____                  Zip: __________ 
Home Phone: (____)____-_______    Work Phone: (____)____-_______    Cell Phone: (____)____-_______                                      
Occupation: _____________________   Employer: __________________  Marital Status: _______________   Name of Spouse/Partner: _________  How Long Have Both of You Been Together?                                 
Religion       
                                                   
If Client is a Minor, Name of Responsible Adult:                                                                                                    
Name of Closest Friend/Relative: ________________________________  Phone: (____)____-_______                                                 
Address ____________________________________________________  City: _________________         State: ______           Zip: ____________               

There are times when prior medical and psychological records will be requested.
Please make sure that all information given below is correct.

 
Do You Smoke? ________   How Much? ________  
Do You Drink? ________     How Much? ________              
Do You Take Drugs? ________   If yes, what kind? _______________ How often? ____________                              
Last Medical Examination:_____________     
Reason ______________________________________________________
_____________________________________________________________                                                                                    
Are You Now Under a Doctor's Care? _____  
Doctor’s name:________________________                                                              
Reason for Doctor’s Care: ______________________________________                                                                                                                                 
Are You Taking Any Medication? ________          
If yes, What Kind?_____________________________________
____________________________________________________                                                                         
Reason for Medication: _________________________________________                                                                                                                                  
Have You Ever Been Hospitalized for a Physical Illness?   Describe:                                                                     
                                                                                                                                                                       
Have you ever been hospitalized for a Mental Illness, Personality Disorder, Anxiety Disorder, etc? Describe:                                                                                                                                                                        
Any Previous Therapy/Counseling?                 
 If Yes, Name and Phone Numbers of Therapists:                                                                                                                                                           
When and Number of Sessions:                                                                                                                         
Type of Therapy/Counseling:                                                                                                                              
How referred to Life Line Counselors:                                                                                                                                

What do you Wish to Achieve with Therapy?                                                                  
Check Any of the Following That May Apply to You:

• Life Line Counselors
• On-Line Scheduling
• Mental Health Blog
• About Me
• Payment
• Important Numbers
• Contact Us
• State Disclosure
• Referral Document
• Intake Form
• Edward A. De Sano III
• Events and Seminars