Intake Forms

Kathy Cox LMT, LCPC

5290 Williams Drive

Roscoe, IL 61073

   815-324-0324

               F: 866-927-3053

                Adult Intake

Marital Status: single engaged married remarried separated divorced widowed Sexual Orientation (optional): ________________________Gender Identification (optional):______________ Presenting Problem - Describe your primary concerns: _____________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Please indicate the severity of your problem on a scale from 0-10. Zero is mild and ten is very severe. 0 1 2 3 4 5 6 7 8 9 10 FAMILY DATA: Does your spouse or romantic partner live with you? Yes No Name: __________________________________ Age: _________ Occupation: ________________________ Describe your relationship with your spouse or romantic partner: ____________________________________ __________________________________________________________________________________________

Children: list the name, sex, age. 1. ____________________________ 2. _______________________________ 3. _______________________ 4. ____________________________ 5. _______________________________ 6. _______________________

Describe your relationship with your children? ___________________________________________________ __________________________________________________________________________________________

List anyone else who lives with you? ____________________________________________________________ __________________________________________________________________________________________

Father: living or deceased If deceased, age at death __________ Cause of death _______________________ Occupation? ___________________ If living, present age ______________ Health: _____________________ Describe your relationship with your father? _____________________________________________________ _____________________________________________________________________________________

Mother: Living or deceased If deceased, age at death __________ Cause of death ______________________

Occupation? _____________________ If living, present age _______________ Health: __________________

Describe your relationship with your mother? ____________________________________________________ _____________________________________________________________________________________

Siblings: # of brothers? __________ Ages: _____________ # of sisters? __________ Ages: ______________ Describe your relationships with your siblings? ___________________________________________________ __________________________________________________________________________________________

How were you disciplined as a child? ___________________________________________________________

Languages spoken in your home: _______________________________________________________________

Does any member of your family have a past or present history of chronic illness? ________________________

 Is there any history of genetic disorders in the family? ______________________________________________

Has any family member had a language or speech problem? _________________________________________

Has any family member experienced emotional problems? Yes No Committed suicide? Yes No __________________________________________________________________________________________

Has any family member experienced problems with alcohol or drugs? __________________________________

Has any family member been hospitalized for psychological reasons? __________________________________

EDUCATIONAL HISTORY Highest grade completed: _____ Last school: _________________ Did you repeat any grade? Yes, No Highest degree attained: GED HS diploma Associate’s Bachelor’s Master’s Doctorate Did you receive any special services inside or outside of school? Yes No Describe: ____________________ _____________________________________________________________________________________

Were you ever placed on probation, suspended, or expelled from school? Yes No Please explain _____________________________________________________________________________ Best Subjects? _________________________________________ Grades in these subjects? _______________ Worst subjects? _______________________________________ Grades in these subjects? _______________ MEDICAL HISTORY Physician’s name: _________________________ Phone: ________________Date of last physical?__________  Height: ____ Weight: ____ Do you exercise? Yes No How Often? ___________________ Any recent weight gain or weight loss? Any recent weight gain or loss? Yes No _________________________________________ List illnesses, injuries, hospitalizations, or surgeries during childhood or adolescence: ____________________ _________________________________________________________________________________________ List illnesses, injuries, hospitalizations, or surgeries during adulthood: ________________________________ __________________________________________________________________________________________ Have you ever had a head injury or been knocked unconscious? Yes No List current medications: _____________________________________________________________________ __________________________________________________________________________________________ List current allergies or health problems: _______________________________________________________________________ How many meals per day? ______________________ Any changes in eating habit? ____________________ How many hours do you sleep at night? ______________ Any changes in sleeping habit? ______________ Do you drink alcohol? __________ How often? _____________ How much? __________________________ Do you use drugs? Yes No How often? _______ How much? _______________________________ Have you had a psychological or psychiatric evaluation? Yes No Explain: _______________________ ________________________________________________________________________________________ Have you ever been in counseling? Yes No Was it helpful? _________________________________ Have you ever taken medication for psychological problems? Yes No Types: OCCUPATIONAL HISTORY Employer: ________________________________Job Title: ___________________ How long? ____________ Address: __________________________________________________________________________________ Are you satisfied with your present work? Why? __________________________________________________ What are your career goals? __________________________________________________________________ Have you ever been fired from a job? Yes No Please explain: _____________________________________ __________________________________________________________________________________________ What kind of jobs have you had in the past? _____________________________________________________ 1047 Cannell Court, Rockton, IL 61072 www.ConnectionsTherapyCenter.com SOCIAL HISTORY Religion (optional) a) in childhood: _______________________ b) as an adult: ______________________ How many friends do you have that you can count on or confide in? __________________________________

Do you have problems making or keeping friends? Yes No Explain: _____________________________ ____________________________________________________________________________________

Have you ever been bullied or severely teased? Yes No Explain: _____________________________ ____________________________________________________________________________________

When you were a child, did anyone ever touch you in a sexual manner? Yes No Who? _________________ How old were you? ________ How many times did it happen? ______________ Have you ever been physically assaulted or beaten up? Yes No By whom? _____________ How old were you? _________ How many times did it happen? ______________ Have you ever been forced to have sex against your will? Yes No By whom? ____________ How old were you? __________ How many times did it happen? ______________ Have you ever had an experience where you were afraid for your safety or the safety of someone close to you? Yes No Explain: __________________________________________________________________ Have you ever been in trouble with the law? Yes No Explain: ______________________________ _________________________________________________________________________________________ What are your hobbies and interests? ___________________________________________________________ __________________________________________________________________________________________ Additional information you feel your therapist should know:_________________________________________ _________________________________________________________________________________________ _____________________________________________________________________________________