Intake Form|Personal Data Inventory | Dr. MAMA| Family Life Educator

Name:

Phone:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Occupation:

Gender:

Birthdate:

Age

Selected Value: 0

Height:

Marital Status:

Education (max):

How did you find out about us?

How would you rate your health?

Very Good
Good
Average
Declining

Weight

Have you had any changes in weight recently?

Yes
No

Gained

Selected Value: 0

Lost

Selected Value: 0

List all important present or past illnesses, injuries or handicaps

Date of last medical examination:

Physician Name:

Physician Address:

Are you presently taking medications?

Yes
No

If so provide a list...

Have you ever used drugs outside of medical purposes?

Yes
No

If so what?

Have you ever had a severe emotional upset?

Yes
No

If so, explain:

Have you ever been arrested?

Yes
No

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?

Yes
No

Have you recently suffered the loss of someone who was close to you?

Yes
No

If so, explain:

Have you recently suffered loss from serious social, business, or other reversals?

Yes
No

If so, explain:

Denomination Preference:

Do you have a membership with a church, if so provide name:

How often do you attend church?

Baptized

Yes
No

Religious Preference of spouse (if married)

Do you consider yourself a religious person?

Yes
No
Uncertain

Do you pray to God?

Often
Occasionally
Never

Do you believe in God?

Yes
No
Uncertain

Are you saved?

Yes
No
No sure what you mean

How often do you read your Bible?

Often
Occasionally
Never

Do you have regular family devotions?

Yes
No

Explain recent changes in your religious life, if any:

Have you ever had any psychotherapy or counseling before?

Yes
No

If yes, list counselor or therapist and dates:

If yes, what was the outcome?

Check any of the following words to best describe you now:

Have you ever felt people were watching you?

Yes
No

Do people's faces ever seem distorted?

Yes
No

Do you ever have difficulty distinguishing faces?

Yes
No

Do colors ever seem to bright or dull?

Yes
No

Are you sometimes unable to judge distances?

Yes
No

Have you ever had any hallucinations?

Yes
No

Are you afraid to be in a car?

Yes
No

Is your hearing exceptionally good?

Yes
No

Do you have problems sleeping?

Yes
No

Name of Spouse:

First

Last

Spouse's Address (if different from above listed)

Address Line 1

Address Line 2

City

State

Zip Code

Spouse's Phone #:

Spouse's Occupation

Spouse's Age

Selected Value: 0

Spouse's Education (max)

Spouse's Religion

Is your spouse willing to come in for counseling?

Yes
No
Uncertain

Have you ever been separated?

Yes
No

If so, why and when?

Has either of you ever filed for divorce?

Yes
No

If so, why and when?

Date of marriage:

How old were you when you married:

Selected Value: 0

Age of spouse when married:

Selected Value: 0

How long did you know your spouse before marriage?

Length of steady dating spouse before marriage?

Length of engagement?

Give brief information about any previous marriages (if any)

Number of children

Selected Value: 0

List names, ages, gender of children. If older than 18 list occupation. (indicate if children are from union or before union)

Explain briefly if you were reared by anyone other than your parents:

List names and ages of all siblings in birth order (include yourself in the order)

Briefly explain your problem:

If you have done anything to help your problem:

What are your expectations of counseling?

How do you see yourself: (do your best to describe)

What, if anything, do you fear?

Is there any other information I should know?