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Adult Intake Form

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Adult Intake Form

WELL MINDS COUNSELING, PLLC

Tana Carpita, MSW, LICSW

2525 E. Arizona Biltmore Circle, Suite B220

Phoenix, Arizona 85016
(425) 588.9280

Client's Name

Prefers to be called:

Date of Birth

Date of Intake

Home Address:

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Phone (Main/Primary):

May I leave a message?

Yes
No

Other Phone:

May I leave a message? (copy)

Yes
No

Insurance Coverage/Company:

If N/A, are you:

Private Pay
Out of Network

WHO DOES CLIENT LIVE WITH:

Name of Person #1

Relationship of Person #1

Age of Person #1

Other Comment About Person #1

Name of Person #2

Relationship of Person #2

Age of Person #2

Other Comment About Person #2

Name of Person #3

Relationship of Person #3

Age of Person #3

Other Comment About Person #3

Name, Relationship, Age, Comments about any other persons living with you:

Are your problems affecting any of the following?

Hygiene
Work/School
Finances
Self-Esteem
Health
Housing
Relationships
Recreational Activities
Legal Matters
Other

If Other:

Tell me about your concerns and expectations

Reason for coming to therapy/counseling now:

What do you hope to achieve through this counseling experience? (Goals? What will be different after working in therapy?)

Medical/Well-being History:

Name of Primary Care Doctor/Clinic:

Current Medical Conditions currently being treated:

Biological/Family History: Mental health, Neurological, Developmental, Learning Diagnoses in Family members:

Client's Current Medications (include prescribed, naturopathic, supplements):

Medication #1 (List name, dose, reason for taking, and start date)

Medication #2 (List name, dose, reason for taking, and start date)

Medication #3 (List name, dose, reason for taking, and start date)

Allergies:

Have you ever experienced any of the following medical conditions?

Asthma
Obesity
Meningitis
Diabetes
High blood pressure
Frequent Headaches
Skin Condition
Seizures/Epilepsy
Hearing problems
Thyroid Condition
Stomach aches
Head injury
Vision problems
Freq. ear infections
Anemia
Chronic pain
Dizziness/fainting
High fevers
Autoimmune disorder
Other

If other:

If you selected any of the above conditions, is this currently (within the last month) bothering you?

Regarding sleep, do you have difficulty:

First N/A
Falling asleep
Waking up in the AM
Staying asleep throughout the night
Other concerns about sleep, fatigue, daytime sleepiness, naps, quality or quantity of sleep?

APPETITE/DIET: Do you have any concerns about your appetite (not feeling hungry, skipping meals, over-eating/eating when not hungry, etc.), or about your diet?

Alcohol/Drug Use:

Do you use alcohol? If so, how many drinks per day? Per week?

Do you smoke? If so, what and how much?

Do you use illegal/illicit drugs?

Do you have a past history of alcohol or drug abuse? If so, explain, including treatment you've had.

Intervention/Counseling History:

Intervention?

None

Have you ever been given a mental health diagnosis?

Yes
No

If so, what?

Have you attended counseling before?

Yes
No

If yes, when?

If yes, where/with whom?

Reason/Initial concern for seeking counseling previously?

Were the primary reasons for seeking counseling in the past resolved to your satisfaction at the time counseling ended? (Please explain):

Please list/describe any other treatments/interventions you have participated in to address primary concerns for seeking counseling now (i.e., Psychiatrist, medication, Groups, Pastor, Occupational Therapy, School Counselor, ABA/Behavioral, Vision therapy, etc.):

Describe Treatment #1: Type, When, Provider/Program, Reason

Describe Treatment #2: Type, When, Provider/Program, Reason

Describe Treatment: Type, When, Provider/Program, Reason

Safety and Client Legal History:

Safety and Client Legal History:

None

Are there any other agencies required/mandated to be involved? (Courts, etc.)?

Yes
No

Have you ever been charged or convicted of a sexual offense against?

Yes
No

Have you ever thought about, made statements about, or attempted to hurt yourself, including suicidal ideation?

Yes
No
Unsure

If yes, please describe:

Have you ever thought about, made statements about, or made attempts, to hurt someone else?

Yes
No
Unsure

If yes, please describe:

Academic and Employment Information:

Highest Grade Completed:

Current Employment

No
Yes
Part-time
Full-time

Position/Job Title:

Does work contribute to current issues/stress?

Strengths, Special Interests, Other needs:

Please describe your strengths, skills, and talents:

Describe any special areas of interest or hobbies (art, books, animals, physical fitness, etc.):

If not already addressed, please comment on, or describe, what information would be most helpful for this therapist to know in order to be of the most help to the client/you/the family?

What qualities in a therapist are important to you?

Contact

Tana Carpita, MSW, LCSW
Well Minds Counseling, PLLC
(425) 588-9280
trcarpita@wellmindscounseling.com

Location

Well Minds Counseling, PLLC
2525 E. Arizona Biltmore
Circle, Suite B220
Phoenix, Arizona 85016

Disclosure

I am an independently licensed clinical social worker, practicing with other clinicians under the name The Biltmore Wellness Collective. Read Full Disclosure

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