Bethesda Counseling Services Client Intake form

Date of Submission

Client Last Name (include two if a couple)*

Client First Name (include two if a couple)*

Client Date of Birth (include two if a couple)*

What languages do you speak?

What is your preferred spoken language?*

Insurance (not applicable for coaching or couples therapy)

Do you prefer sessions to be virtual or in person?*

Virtual

In-Person

Either- Whatever is available first

What brings you to coaching or counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can*

Are you...*

Not meeting your full potential

Busy but not productive

Unbalanced with demands of work, family, & personal needs

Struggling to make sustainable, lasting change

Making an important life transition

Unsure how to implement tools you are learning

None of the above

Do you live alone, with family, with others etc.*

If you are in a relationship, please describe the nature of the relationship and months or years together*

If you are the client's parent, are you divorced or in the process of separation?*

Will you need an absent excuse letter for school/work?*

Yes

No

What is your current occupation? What do you do? How long have you been doing it?*

Name of Person Completing this Form*

Relationship to Client*

Phone Number*

Phone

Additonal Phone #

Phone

Address of client (must provide state)*

Email Address (include two if a couple or family)*

Additional Email

How did you hear from us (e.g., friend recommendation, doctor referral, Google search, provider directory search, etc.)?*

Insurance Provider name or enter Self-Pay*

Insurance Name and ID number*

Subscriber Full Name

Subscriber Date of Birth*

Upload insurance cards if you would like your benefits pulled

File Upload

Drag and drop files here or

Best way to contact you*

Email

Phone

Have you seen a mental health professional before? If so, please specify dates, the reason for counseling and your experience. What was your diagnosis, if any?*

Have you ever been hospitalized for a psychiatric issue? If yes, when, why and for how long?*

Specify all psychotropic medications you are currently taking, for how long, and for what reason. What is the dosage of each? What time of day do you take it (morning, evening, bedtime)? Does it help?*

Do you have any issues with alcohol/drugs?*

Yes

No

Do you have or have ever had suicidal thoughts? If yes, when*

Have you ever attempted suicide? Please list all attempts and your age when each happened, starting from the most recent event to the oldest event.*

Do you have thoughts or urges to harm others?*

Yes

No

Are you involved in any legal action (civil or criminal) such as child custody? If yes, please explain*

Please provide an emergency contact (name, relationship to you and phone number)*

Additional information or Provider Request

Stay on the waitlist no matter the time*

One month

Three months

Six months

Stay on the waitlist no matter the time

Send me a copy of my responses