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Please print this page and bring it completed to your first appointment

Jane Bisco, LCSW-C

Adult Intake Form

Date: _______________

Personal Information

Last Name: _________________________ First Name: _________________________ M.I.: ________

Age: _____ Date of Birth: _______________ Gender: _____ Social Security #: __________________

Street Address: ________________________________________________________ 

City: _________________________ State: _____ Zip code: _______________

Ok to send mail: _____   Email:  _________________________________

Home phone: _________________________ Ok to leave a message: _____

Cell phone: ___________________________ Ok to leave a message: _____

Work phone: __________________________ Ok to leave a message: _____


Name of emergency contact: _____________________________ Relationship to you: _______________

Address: _____________________________________________________________________________

Home Phone: _____________________________ Cell/Work Phone: ____________________________


Referral Source (how you heard about counseling services): ____________________________________


Health Information

Please answer the following questions using: 5 . Excellent, 4 . Good, 3 . Average, 2 . Poor, 1 - Failing

 How would you currently rate your physical health: _____

How would you currently rate your mental health: _____

How would you currently rate your spiritual health: _____ (if does not apply to you, please use N/A)

 Please list current symptoms (reason you are here) and circle those you currently find most bothersome:  _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 Medical Information

Do you now have, or have you had in the past, any of the following? Check all that apply:

Asthma Allergies Headaches

Brain Injury Epilepsy Seizures

Digestive Disorders Cancer Diabetes

Breathing Problems Immune System Problems Heart Disease

High Blood Pressure Vision Problems Hearing Problems Arthritis Urinary Disorders

Tuberculosis Thyroid Disorder Multiple Sclerosis Chronic Fatigue Syndrome

Fibromyalgia Pregnancy (how many) Miscarriage (how many) Abortion (how many)

Sexually Transmitted Disease Sleep Disorder Serious Accident  Surgery /Other


Are you currently under the care of a Doctor or other medical health professional: _____

Name of Primary Care Physician: _________________________ Physician Phone #: _______________

Address: _____________________________________________________________________________

Name of Specialist Physician: ____________________________ Physician Phone#: _______________

Address: _____________________________________________________________________________


Please list any prescription medications you are currently taking: ________________________________ __________________________________________________________________________________________________________________________________________________________________________

Please list any over the counter medications, vitamins, or herbal supplements you are currently taking: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Do you currently exercise: _____ If yes, please indicate how many times per week: _____


Please indicate substances currently used (over the past 6 months), how much at one time, how many

times per day/week, age of first use, past use history, and length of time used.

Substance Current Amount Frequency Age Past Length

Caffeine Alcohol Tobacco Marijuana Ecstasy Cocaine/Crack Heroin

Methamphetamines PCP/LSD/Mushrooms Pain Killers Steroids Tranquilizers

Sleeping Pills Diet Pills

Have you ever believed your substance use was a problem for you: ______________________________

Has anyone ever told you they believed your substance use was a problem: _______________________

Have you ever had withdrawal symptoms when trying to stop using any substances: ________________

Have you ever had problems with work, relationships, health, the law, etc. due to your substance use? If yes, please describe: ____________________________________________________________________

Have you ever participated in drug and alcohol treatment: _____ If yes, please list type, length, dates, and age at time you received these services: ___________________________________________________

Do you currently or have you ever attended Alcoholics or Narcotics Anonymous: _____ If yes, please list

length of time sober and number of meetings you attend per week: _____________________________


Mental Health Information

Have you ever been in counseling/therapy before: _____ If yes did you find it helpful or effective: _____

Are you currently receiving mental health services: _____ If yes, please list name of practitioner and type of services you are receiving: _____________________________________________________________


Have you ever been hospitalized for mental health concerns: _____ If yes, list date(s) and length of stay:

Have you ever been diagnosed with a mental illness? If yes, please list illness(es) and date (s) first

diagnosed: ____________________________________________________________________________


Has anyone in your family ever been diagnosed with a mental illness? If yes, please list relationship(s)

and illness(es): ________________________________________________________________________

Have you ever or are you currently engaging in self harm? Currently: _____ Past: _____

Have you ever or are you currently contemplating suicide? Currently: _____ Past: _____

Have you ever or are you currently contemplating harming another person? Currently: _____ Past: _____

Have you ever attempted suicide: _____ If yes please list date(s), method(s), and your age at time of

attempt: _____________________________________________________________________________

 Has any one in your family ever attempted suicide: _____ If yes please list relationship: _____________


Do you currently or have you ever had trouble sleeping: _____ If yes, please describe: ______________

Do you currently or have you ever had problems with eating or with food: _____ If yes, please describe:

Briefly describe why you are coming in for counseling and the goals you hope to achieve in therapy:


 Spiritual Information

Have you ever or do you currently engage in a personal faith practice: _____ If yes please describe:

Have you ever, or do you currently belong to a faith community (church, synagogue, temple, religious

order, etc.: _____ If yes, please describe your current level of connection and involvement:

Do you want to incorporate your faith/spirituality into the counseling process: _____ If yes, please

describe how you would like to do so, and if you are specifically seeking spiritual guidance or direction:


Relationship Information

Are you currently in a relationship: _____ If yes, please list status: ______________________________

Name of Person: __________________________ Length of time you have known each other: ________

Length of time you have been together: _____________________ Do you currently live together: _____

Number of marriages: _____ Number of divorces: _____ If widowed, your age at death of spouse: ____

Do you have children: _____ If yes, please list below:

 Name   Age        Lives with you                                                                                   Name   Age       Lives with you


If you are coming in for Couples or Family counseling, or are currently experiencing relationship

difficulties you would like to address in individual counseling, please briefly describe: _______________

Other persons living in your household and your relationship to them: ____________________________


Family Information

Were you adopted: _____ If yes, your age at time of adoption: _____

With whom did you live until the age of 18: _________________________________________________

Did your parents ever divorce: _____ If yes, your age at time of divorce: _____

If divorced, did your parents ever re-marry: _____ If yes, list parent(s) and your age(s) at time of

remarriage: __________________________________________________________________________

 Were you ever in foster care or residential care: _____ If yes, please list age and living situation:


Please indicate if you or a member of your immediate family experienced any of the following. If a

family member, please indicate relationship(s):

Emotional Abuse Legal Problems Physical Abuse Frequent/Multiple Moves

Sexual Abuse Homelessness Domestic Violence Financial Problems Neglect

 Lived over-seas Substance Abuse Military member Serious Illness

 Discrimination Accident or Injury


Educational Information

Number of years of education completed: _____ Degree(s) achieved ________________________

Are you currently employed: _____ If yes, please list position title, name of employer, type of work, and

length of time at employment: ___________________________________________________________

If you are not currently working, how long have you been un-employed: __________________________

What types of jobs have you typically held: _________________________________________________

Have you ever served in the military: _____ If yes, please list branch, rank, and current status

(active/discharged): ____________________________________________________________________

If deployed please list dates and family/relationship status pre and post deployment: ________________


Please list your personal hobbies and interests: _____________________________________________________________________________________


Legal Information

Have you ever been the victim of a crime:_____ If yes, please list date and briefly describe: __________

Are you currently involved in divorce or child custody proceedings: _____ If yes, please explain: _____

Have you ever been convicted of a misdemeanor or felony: _____ If yes, please explain: ____________