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Client NameArrow Counseling Services, LLCADULT AND ADOLESCENT (14 YRS OLD AND OLDER) INTAKE ASSESSMENTPlease complete this form before your first appointment. All information contained herein is confidential inaccordance with the attached policies and procedures and in accordance with the HIPAA Privacy Act. Thisinformation is requested to obtain the best level of treatment and care possible.Name:Address:SS#:Date of BirthGender: Male Female (Circle One)Age:How would you like us to contact you? (Please circle response)Home:yes or no Phone:Work:yes or no Phone:Cell phone: yes or no Phone:Email:yes or no Email address:Other:Name of person completing form:Relationship to person receiving services:In case of an emergency during a therapy session if I become unable to communicate or need nonmedical assistance, the person I authorize you to contact is located on the Intake Form.Name:Contact Phone:Special Needs1. Do you have a need for Assistive Technology (interpreter, verbal instructions, etc.) inthe Provision of Services? Yes NoIf yes, Describe:2. Do you have any other disabilities, disorders or concerns in the area of Special Needs ?Yes NoIf yes, Describe:Current Presenting Issue/Concern1.Presenting Problem/ Chief Complaint (include impact on social, work, and/or academic functioning):1
Client Name2. Please check any of the following problems that you currently are or recently have experienced:Stress Other relational problems Sexual Abuse Alcohol Use Work stress Chronic pain Financial problems Obsessive thoughts Parenting problems Marital Problems Hallucinations Depression Verbal Abuse Drug use Trouble sleeping Anger Legal matters Grief Compulsive Behaviors Panic Attacks Emotional Abuse Eating problems Gender Identity Issues Abortion Recent death Fears Controlled by others Anxiety Physical Abuse Racing thoughts Sexual Problems Pregnancy Career choices Controlling Spiritual problems Other: 3. Please indicate the severity of the symptoms you are experiencing:Symptoms Experienced in thelast two (2) weeksAggression toward othersAnger OutburstsAnxietyAttention-DeficitAvoidant behaviorsCan’t be aloneBingingCompulsive BehaviorsCryingDisruptive BehaviorDrug or Alcohol UseEnuresis/ EncopresisFear of crowdsFear of leaving homeFeeling EmptyFeeling worthlessFinancial ProblemsFire settingFlashbacksGamblingGrandiose Thoughts of selfHallucinationsHeadachesHearing VoicesHoardingHomicidal IdeationHurts animalsHyperactivityImpulse ControlNoneNot atallSlightRare, lessthan a dayor twoMildSeveraldaysModerateMore thanhalf thedaysSevereNearlyevery dayIf longer than 2weeks pleaseindicate the # ofweeks, months, yearsW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, Y2
Client NameIndecisivenessInfidelityIrritableIsolatedLack of eatingLack of pleasure in doingthingsLack of TrustLegal IssuesLonelyLyingManipulativeMemory lossMood swingsNightmaresObsessive ThoughtsOppositional DefiantOut of body experiencesOvereatingPanic AttacksPhysical fightsPhysical painPoor concentrationPoor Self EsteemPoor sleepPornographyPost Partum DepressionPurging FoodRacing HeartRelationship IssuesRestricting FoodRisk TakingSadSelf-Harm BehaviorsSexual DysfunctionSexual Identity ConfusionSexually PromiscuousSleep DisturbanceSpiritual ConfusionSuicidal IdeationSuspicious of othersUncontrolled spendingUnwanted memoriesVerbal fightsW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, YW, M, Y3
Client Name4. Are your problems and/or symptoms affecting any of the following?Handling everyday tasksSelf esteemRelationshipsWork/SchoolHousingLegal mattersRecreational activitiesSexual activityHealth5. Are you motivated or hopeful about treatment, change, and the future?HygieneFinancesYesNoPlease circle the number that best indicates how motivated you are for change123Minimally motivated4567Moderately motivated8910Extremely motivatedCurrent and Past Psychiatric Treatment1. Are you currently or have you ever been in psychiatric treatment of any type?Yes NoType of TreatmentOutpatient CounselingWhen? Provider/ProgramReason for TreatmentMedication (mental health)Psychiatric HospitalizationDrug/Alcohol TreatmentSelf-help/Support Groups2. Did you have a positive experience in your previous treatment?YesNo3. Were you compliant with previous treatment?YesNo4. Any history of thoughts/plans/acts/ideation or intention of suicide?Yes NoIf yes, circle all that apply:Passive ThoughtsSingle AttemptMultiple AttemptsIf yes, explain:5. Do you currently have any thoughts/plans/acts/ideation or intention of suicide? Yes NoIf yes, describe:6. Any history of thoughts/plans/acts/ideation or intention of homicide?Yes NoIf yes, circle all that apply:Passive ThoughtsViolence Towards AnotherIf yes, explain:7. Do you currently have any thoughts/plans/acts or intention of homicide? YesNoIf yes, describe:If you answered yes to the above questions, what things happen that make you want to harm yourself or others?4
Client Name8. Do you feel that you are currently (within the past 6 months) at risk for Dangerous Behaviors?YesNoIf yes, identify any situation that increases risk for dangerous behaviors:If yes, how do you currently cope or deal with these risks?If yes, describe any warning signs related to the risks of dangerous behaviors:MEDICAL INFORMATION1. Do you take any medications for any reason?YesNo2. Have you always taken your medications as prescribed in the past?YesNoMedication: Please list all medications including prescribed, over the counter and homeopathic.NameDosageFrequencyPrescribed ByReason for prescriptionMedical Providers:3. Please list all Health Care Providers:NameMay we contact them to coordinate care?Phone numberPrimary Care PhysicianYesNoPsychiatristYesNoCaseworkerYesNoCase ManagerYesNoOtherYesNo5
Client Name4. Medical History: Circle all that apply:Breathing ProblemsDiabetesHigh Blood PressureHigh CholesterolHeart ProblemsImpaired Ability to Walk Infectious DiseaseImpaired HearingThyroidImpaired VisionLiver ProblemsMR/DD/LDObesitySeizure DisorderUlcerGI ProblemsOther:5. Any concerns regarding medical history:6. Number of pregnancies: Number of Live Births:Birth Control? YesNo7. Any allergies or special precautions?YesNoUnknownIf yes, circle all that apply:SeasonalMedicationsFoodLatexAnimalsOtherIf yes, specify:8. Do you have any special nursing/medical needs?YesNoIf yes, circle all that apply:WalkingHome Health MonitoringNursing HomeDialysisClinic Visits/InjectionsOxygen/Portable OxygenPacemakerOtherIf yes, specify:9. Do you experience limitations due to physical health or disability?YesNoIf yes, circle all that apply:LiftingNot Able to WorkStrenuous ActivitiesOtherIf yes, explain:10. HeightWeightBMIIf BMI is outside of Healthy Range, would you like strategies to address this issue?YesNoSUBSTANCE USE1. Please check all that apply:Drugs, Alcohol, or Substances:Substance TypeCurrent Use (last 6 months)YNFrequencyPast rijuanaCocaine/crack6
Client NameEcstasyHeroinInhalantsMethamphetaminesPain KillersPCP/LSDSteroidsTranquilizersDEPENDENCE2. Do you find yourself using more of your chosen substance?3. Do you suffer from withdrawal when you try to quit?4. Do you use to excess?DOES (OR HAS) YOUR USE:5. Interfere with your daily life?6. Place you in hazardous situations?7. Cause you legal problems?8. Cause you interpersonal conflict?YesYesYesYesYesYesYesNoNoNoNoNoNoNoOTHER ADDICTIONSGAMBLING9. Any history of gambling?Yes NoIf yes, Describe:SEX10. Any history of sexual acting out, pornography, sex crimes, legal charges, harmful behaviors, etc.?Yes NoIf yes, Describe:FOOD11. Any history of overeating, restricting, and/or purging food? YesNoIf yes, Describe:OTHER ADDICTION CONCERNS (internet, video games, social media, shopping, etc.)12. Please describe:MILITARY HISTORY1. Have you ever served in the military? Yes NoAre you currently serving? Yes NoIf yes, what branch?7
Client NameIf yes, type of discharge (Circle): Honorable Dishonorable GeneralOtherN/A2. If yes, Circle all that apply:Positive Military ExperienceExperienced Combat SituationsNo Traumatic ExperiencesExperienced Traumatic EventsAWOLInjury/ Disability from ExperienceOther comments on the experience, any trauma, etc.:TRAUMATIC EVENTS1. Have you ever witnessed Domestic Violence?YesNoIf yes, please explain:2. Any current or past experience of trauma:If yes, circle all that apply:Emotional AbuseSexual AbuseWitnessed Domestic ViolenceYesNeglectVerbal AbuseWitnessed AbuseNoPhysical AbuseDomestic ViolenceOther:If yes, describe the above or any other traumatic experience:3. Have you received services for past trauma?If no, would you be interested in receiving services?YesYesNo N/ANo N/AIntimate Relationships, Social and Current Living Situation1. Current marital status:SingleMarriedDivorcedWidowedPartnerNumber of times married:If married (or in a significant relationship) more than once, explain reasons for eachdivorce or separation:2. Current problems with intimate relationships (spouse, friends, children, etc.)?Yes NoIf Yes, please describe8
Client Name3.Please list all persons living with you (including spouse, children- step, adopted or foster, extended family, friends,etc.)NameSexBirthdateRelationship To YouAdditional Information4. Are there any issues with your current living situation?YesNoIf yes, please describeFAMILY1. Please list the following people in your life:RelationshipNameBirthdateDescribe him/her (e.g. angry, outgoing,supportive, gsSpouse/partnerChildren2. Describe your childhood and adolescence (atmosphere, location, significant events).Circle all that apply:Parents DivorcedParents SeparatedParents RemarriedNo Involvement of Biological ParentsParent(s) DeceasedRaised by GrandparentsRaised by OthersGood/Happy HomeStrict HomeReligious HomeUnfair HomeAbusive HomeAbsent FamilyMultiple HomesOtherExplain:3. Are significant issues from childhood impacting current presenting problem? Yes NoIf yes, Circle all that apply:9
Client NameTrust Issues with Current RelationshipsIntrusive MemoriesDifficulty with Activities of Daily LivingOngoing Tense Relationships with FamilyDifficulty with Academic/School FunctioningLoss of Family with Residual FeelingsExplain:4. How well did your parents/guardians get along with each other?GreatGoodFairPoorTerrible5. How well did you get along with your parents/guardians?GreatGoodFairPoorTerrible6. Have any family members had a history of Mental Illness:If yes, please describe below:Who?Family Mental HealthProblemsHyperactivitySexually AbusedDepressionManic DepressionSuicideAnxietyPanic niaEating DisorderAlcohol AbuseDrug AbuseMental Retardation7. Family History of Medical Problems? YesWho?Family Medical HealthProblemsHeart ProblemsCancerDiabetesThyroidYesNoPlease DescribeNoPlease DescribeCULTURAL, GENDER, AND SPIRITUAL CONSIDERATIONS1. Primary cultural/ethnic group? CaucasianAmerican10
Client Name3. Primary Sub-culture LGBT Medical Field- Runners, etc.-4. Any Gender and/or Sexual Orientation Issues? YesNoIf yes, describe issues:5. Primary Religious Affiliation Circle any that apply: Christian Other6. What are your spiritual beliefs and practices?7. How often are you involved in religious or spiritual practices? Circle all that applyRegular InvolvementOccasional InvolvementSpecial Celebrations/Holiday InvolvementNo Involvement8. Do you have spiritual strengths?No YesPlease describe9. Do you have spiritual problems/issues?No YesPlease describeEDUCATIONAL AND DEVELOPMENTAL INFORMATION1. Do you have any problems of an academic nature?YesNoIf yes, describe issues:2. Please check the level of education you have completed:HS GraduateGEDSome CollegeAA/2 yrs collegeSome Graduate SchoolMA/2 yrs graduatePh.D/4 yrs graduate school3. Were you in special education classes?YesBA/BS 4 yrsPost-GraduateNo Unknown4. Describe how you did in school. Circle all that apply:11
Client NameGood/Decent GradesLearning DisabilityFrequent Behavior IssuesFair/Poor GradesNo Behavior IssuesSuspended/ExpelledRetainedSome Behavior IssuesDropped out5. Do you have a history of any developmental delays or issues?Yes NoIf yes, specify:6. Do you have qualities that could be academic strengths?YesNoIf yes, specify:VOCATIONAL INFORMATION1. Current employment status. (Circle):Active MilitaryCriminal InmateEmployed Full-TimeEmployed Part-TimeRetiredUnemployed--Not SeekingDisabledFull-Time StudentUnemployed--Seeking2. How long at current job? Days/Weeks/Months/Years3. Do you have problems of a vocational nature?YesNo4. Are you satisfied with your current job?YesNo5. Have you experienced difficulty performing work or work-like activity?YesNoIf yes, Circle all that applyOn DisabilityApplied for DisabilityDifficulty Maintaining JobsNo Work HistoryDifficulty with Social Work InteractionsMedical Problems InterfereDescribe the severity/frequency of work problems of any kind:Work History (List Current or Most Recent First):Employer:Start/End Dates:Duties, Performance, Strengths/Problems:Financial Information1. Source of income or support received during the last 12 months: Circle all that applyWagesDisabilityIllegal ActivityLoansNoneParentsRetirementSocial SecuritySpouse/Significant Other ChildrenOther:2. Do you currently have financial problems?YesNoIf yes, Circle all that apply:Currently UnemployedNumerous Medical Problems/BillsDifficulty Paying BillsDifficulty Paying UtilitiesOwing/Paying Child SupportLegal/Probation FeesCannot Afford MedicationsPossible HomelessnessOther12
Client NameIf yes, explain:LEGAL HISTORY1. Have you ever been arrested?YesNo2. Do you have any present legal involvement:YesNoIf yes, Circle all that apply:Arrested, Not ConvictedAssaultAwaiting Sentence Awaiting TrialConvicted, Served TimeCurrently in JailCurrently in Prison Deferred AdjudicationDeferred ProsecutionDrug/Alcohol Offense On BailOn ParoleOn ProbationSex OffenderOther:Explain:3. Do you have any past legal involvement:Yes NoIf yes, Circle all that apply:Arrested, Not ConvictedAssaultAwaiting Sentence Awaiting TrialConvicted, Served TimeCurrently in JailCurrently in Prison Deferred AdjudicationDeferred ProsecutionDrug/Alcohol Offense On BailOn ParoleOn ProbationSex OffenderOther:Explain:STRENGTHS/WEAKNESSES/ BARRIERS TO TREATMENT1. Describe any leisure activities or hobbies: Circle all that applyHunting/FishingSpending Time with Family Playing on the ComputerChurch ActivitiesReadingCookingWorking OutsideShoppingExercisingHome ImprovementWater ActivitiesOtherComments:2. Who makes up your current support system? Circle all that d FamilyFriendsImmediate FamilyNoneReligious OrganizationSelf-help GroupSocial Service GroupTeachersOther:3. How do you cope with life events and daily stress? Please check all that applyTalk to familyTalk to friendsPrayTalk with professionalTalk to support groupResources on internetJournalYoga/ExerciseOtherOtherOtherOther13
Client Name4. Please list your strengths: Circle all that apply:AccurateAction nsiderateCourageousCreativityCritical lyGenerousGood dealisticIndependentIngenuityIndustriousnessInner eableLeadershipLivelyLogicalLoveLove of enOpen ople ciseProblem solvingPrudenceRespectfulResponsibleSelf assuredSeriousSelf controlledSpeakingSpiritualitySpontaneousSocial intelligenceSocial skillsStraightforwardStrategicthinkingTactfulTeam :Other:Other:5. Are there any barriers or challenges to treatment and to change? Yes NoIf yes, circle all that applyAngerAggressionChildcareCultural BeliefsFamily MembersHigh AnxietyUnstable Living ConditionsMedical ComplicationsMemory Impairment PregnancyPast Treatment ExperienceReligious BeliefsSevere Depression Substance UseMedication Side EffectsTransportationWork ScheduleOther:Explain:14
Client NamePlease check which Stage of Change best describes you at this time Stage #1: Pre-ContemplationThe Client may be aware of the costs of his/her dysfunctional behavior, however, he/she does not see them assignificant as compared to the benefits. Of course, others may view this situation differently. The Client showscharacteristics of interest in change, but has no plan or intention to change. The Client could be described asunaware. Stage#2: ContemplationThe Client has become aware of problems associated with his/her behavior, however, he/she is ambivalentabout whether or not it is worthwhile to change. The Client is exploring the potential to change; desiring changebut lacking the confidence and commitment to change behavior; and having the intention to change at someunspecified time in the future. The Client can be described as aware and open to change. Stage #3: PreparationThe client has made a decision to change and has concluded that the negatives of their behavior outweigh thepositives. This decision represents an event, not a process.The client accepts responsibility to change his/her behavior. He/ She has evaluated and selected techniques forbehavioral change. Characteristics of this stage include: developing a plan to make the needed changes;building confidence and commitment to change; and having the intention to change within one month. The Clientcan be described as willing to change and anticipating of the benefits of change. Stage #4: ActionThe Client is engaging in self-directed behavioral change efforts while gaining new insights and developing newskills. The Client is consciously choosing new behavior; learning to overcome the tendencies toward unwantedbehavior; and engaging in change actions for less than six months. The Client is described as enthusiasticallyembracing change and gaining momentum. Stage #5: MaintenanceThe Client has mastered the ability to sustain new behavior with minimal effort. He/ She has established newbehavioral patterns. The Client is remaining alert to high-risk situations; maintaining a focus on relapse15
Client Nameprevention; and behavioral change that has been sustained approximately six months. The Client can bedescribed as persevering and consolidating their change efforts. He/ She is integrating change into the way theylive their life. Stage #6: TerminationThe Client has adopted a new self-image consistent with desired behavior and lifestyle. The Client does notreact to triggers/temptations in any situation. The client is confidence; enjoying self-control; and appreciation of ahealthier and happier life. The relapse prevention plan has evolved into the pursuit of a meaningful and healthylifestyle. As such, relapse into the former way of life becomes almost unthinkable.I have answered truthfully and to the best of my ability regarding all of the information contained inthis Adult Intake Assessment.Initial Goals for Treatment:1.2.3.Patient SignatureDateTherapist SignatureDate16
Client NameCrisis and Safety Plan forStep 1: Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be developing:1.2.3.4.Step 2: Internal coping strategies – Things I can do to take my mind off my problems without contacting anotherperson (relaxation technique, physical activity): See Coping Technique Handout1.2.3.4.Step 3: People whom I can ask for help and social settings that provide distraction:1. Name Phone2. Name Phone3. Place4. PlaceStep 4: Professionals or agencies I can contact during a crisis:1. Clinician Name Phone2. Clinician Name Phone3. Arrow Counseling After Hour Emergency phone number: (717) 758-80754. Crisis Intervention Services Phone number: 717-851-53205. Hospital Address: York Hospital, 1001 S. George St, York Pa 17401; Memorial Hospital, 325 S. Belmont St,York, PA 17405: Hanover Hospital , 300 Highland Ave, Hanover, PA 173316. Emergency Services: Dial 911 on phoneStep 5: Making the environment safe:1.2.Step 6: Medications I can take during a crisis (Take as prescribed by medical doctor)NameDosageFrequencyPrescribed ByI will not hurt myself or anyone else, but rather will abide by this plan and seek help during a crisis.Patient SignatureDateTherapist SignatureDate17
Client NameMental Status Exam (For Clinician Use Only) PatientAppearanceMoodAttitudeWell rativeBizarreAnxiousSuspiciousBody or ActivityAffectThought itatedFlatSomatic HallucinationsAuditoryLabileVisualDeniesDelusional BeliefsBizarre DelusionsReligiousThought BroadcastingSomaticThought InsertionPersonPersecutoryThought WithdrawalPlaceGrandiosityDeniesTimeBeing controlledResponds to nameIdeas of referenceKnows familiar faces or placesDeniesOrientationThought ProcessKnows own daily tNormalGoodLoose AssociationsSoftFairFlight of ideasLoudPoorconcrete thinkingPressuredHaltingInability to abstractFollow 1-step ommand HallucinationsNonverbalHarm to selfLimited communication skillsHarm to othersUses yes/no onlyCan resist commandsUses a picture boardDeniesTherapist SignatureDate18
Arrow Counseling Services, LLC ADULT AND ADOLESCENT (14 YRS OLD AND OLDER) . the person I authorize you to contact is located on the Intake Form. Name: _ Contact Phone: _ Special Needs 1. Do you have a need for Assistive Technology (interpreter, verbal instructions, etc.) in . Chronic pain Trouble sleeping Abortion Career choices .
