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Rachel Falbo Counseling INTAKE FORM Date of First Appointment: ______________

Email: ________________________

Name:________________________________________________________________________ Last First MI DOB ______________________________________________________________________________ Address ______________________________________________________________________________ City State Zip Code Phone Numbers:____________________ ___________________ ______________________ Home Cell Work May I leave a message for you at home? Y / N May I leave a message for you at work? Y / N May I leave a message for you on your cell? Y / N May I contact you via email? Y / N Please list the email address that you wish to be contacted at (I do not release email addresses): ____________________________________________________________________________ (I cannot ensure confidentiality of any correspondence sent via email and cannot be responsible for breaches in confidentiality) Race/Ethnicity: ________________________________________________________________ Relationship Status: Married _______ Single _______ Divorced _______ Widowed _______ Cohabitating _______ Other _______ Sexual Orientation: _____________________________________________________________ Education Level: Elementary/Middle School _______ High School/GED _______ Some College _______ Bachelor’s Degree _______ Graduate Degree _______ Other _______ Occupation: ____________________________ Employer: ___________________________ Employer Address: ______________________________________________________________

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Please list all current members of your household: Name

Age

Relationship

Occupation

Briefly describe your reason for seeking counseling: ______________________________________________________________________________ ______________________________________________________________________________ What goals do you hope to achieve by attending counseling? ______________________________________________________________________________ ______________________________________________________________________________

Medical Doctor: __________________________ Phone number: ________________________ When were you last examined by a physician? ______________________________________________________________________________ List any major health problems for which you currently receive treatment: ______________________________________________________________________________ ______________________________________________________________________________ Please list any medications you are currently taking: Medication

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Dosage

Condition

Treating Provider

Length of use of Medication


Current Height _______________________ Current Weight _______________________ Are you currently involved in an exercise regimen? Yes ______ No _______ If yes, please list the type of exercise and amount per week ______________________________________________________________________________ Current hobbies/personal interests: ______________________________________________________________________________ ______________________________________________________________________________ Current religious/spiritual beliefs: ______________________________________________________________________________ ______________________________________________________________________________ Please answer the following, as it applies to you: Do you currently drink alcohol and if so please state the amount consumed per day/week: ______________________________________________________________________________ Do you currently smoke and if so please state the amount consumed per day/week: ______________________________________________________________________________ Do you currently use any controlled substances and if so please state the amount consumed per day/week: _____________________________________________________________________ Have you ever previously attended therapy or received counseling services of any kind? Yes _______ No _______ If yes please list the type of therapy you received ______________________________________________________________________________ Did you find treatment helpful? ____________________________________________________ Previous therapist: ______________________________________________________________ Reason treatment terminated?______________________________________________________ Previous psychiatric hospitalizations? _______________________________________________

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Treatment and Diagnosis Rendered? ________________________________________________ Any family history of alcoholism or drug addiction, and if so, whom? ______________________________________________________________________________ Any family history of any psychiatric disorders, and if so, whom? ______________________________________________________________________________ Do you anticipate being involved in a lawsuit in the near future? Y / N If yes, please explain ____________________________________________________________ ______________________________________________________________________________ Have you ever been a party to a lawsuit? Y / N If yes, please provide the description of the suite, the date, and the outcome: ______________________________________________________________________________ ______________________________________________________________________________ How did you hear about Rachel Falbo Counseling? ____________________________________ ______________________________________________________________________________

I authorize payment of medical benefits to the provider of services, and the release of any treatment information necessary to process claims or obtain authorizations for treatment: Signature ____________________________________

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Date _________________________

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