Couples Counseling Intake Form

In 1. Admission, enter the Admission date (MM/DD/YYYY), the Client or record number and the Intake staff.

Under Program requested: Withdrawal management (detox), Residential, Partial hospitalization, Intensive outpatient and Outpatient.

In 2. Applicant, enter the First name, Middle name and Last name, then the Preferred name, Date of birth (MM/DD/YYYY) and Age, then the Sex, Gender identity and Preferred language.

Enter the Street address, the City, State and ZIP code, and the Telephone, Other telephone and Email address.

Under Marital status: Single, Married or partnered, Separated, Divorced and Widowed.

Under Employment: Full time, Part time, Unemployed, Student, Retired and Disabled; then enter the Employer or school and the Highest education completed.

Under Living situation: Own or rent, With family or friends, Sober living, Shelter and No stable housing; then enter the Children or dependents in your care (number and ages).

In 3. Emergency contacts, enter the Name, Relationship and Telephone, then the Second contact name, Relationship and Telephone.

In 4. Referral, under Referred by: Self, Family or friend, Physician or clinic, Hospital or emergency room, Court, probation or parole, Employer, School and Other.

Enter the Referring person or agency, the Telephone and the Reason for seeking treatment now.

In 5. Insurance or payer, under Payment source: Private insurance, Medicaid, Medicare, Self pay, Grant or public funding and Other.

Enter the Insurance company, Insurer telephone, Member ID, Group number and Policy holder, then the Relationship to policy holder, the Policy holder's date of birth (MM/DD/YYYY) and the Secondary insurance (company and member ID).

In 6. Substance use history, list each substance used, including in the past: Alcohol, Cannabis, Cocaine or crack, Methamphetamine or stimulants, Heroin or fentanyl, Prescription opioids, Benzodiazepines or sedatives, Hallucinogens, Inhalants, Tobacco or nicotine and Other. For each, enter the Age at first use, Date of last use, How often, Amount and Route (oral, smoked, nasal, injected).

Enter the Main substance of concern and the Longest period without use.

Under Ever experienced: Withdrawal seizures, Delirium tremens, Overdose, Blackouts, Injection drug use and Shared needles.

Enter the Current withdrawal symptoms, if any.

Under Prior treatment, enter the Program or provider, Type of care, Dates and Completed (yes or no).

In 7. Medical history, under Conditions, past or present: Hepatitis B or C, HIV, Tuberculosis, Diabetes, High blood pressure, Heart disease, Seizure disorder, Liver disease, Asthma or lung disease, Chronic pain, Currently pregnant and Other.

Enter the Other conditions or details and the Allergies (medications, food, other).

Enter the Primary care provider and Telephone, then under Current medications the Medication, Dose, How often, Prescriber and Reason.

In 8. Mental health history, under Diagnosed or treated for: Depression, Anxiety, Bipolar disorder, PTSD or trauma, Psychosis, ADHD, Eating disorder and Other.

Enter Yes or No for History of self harm or suicide attempt and to Current thoughts of harming yourself or others.

Enter the Current counselor or psychiatrist and Telephone.

In 9. Legal involvement, under Current legal status: None, Probation, Parole, Pending charges, Court ordered treatment, Drug court and Impaired driving case.

Enter the Probation or parole officer, Telephone and Next court date (MM/DD/YYYY).

By signing under 10. Signatures, you certify that the entries are complete and correct.

The Parent or guardian (if the applicant is a minor) enters the Printed name, Signature and Date.

The Intake staff enters the Printed name, Signature and Date.