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Family Impact Centers

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Intake Form

Family Impact Wellness Center

CLIENT INTAKE FORM

Today’s Date

Client’s Name

Age

Birthdate

Parent/Guardian name (s)

Age

Address

Street

City

State

Zip

Phone (home)

(work)

Best time to call

Marital Status

single

engaged

married / how long

times married

Separated / how long

divorced / how long

Education

Occupation

Spouse’s Name

Age

Birthday

Spouse’s Educaion

Spouse’s Occupation

B. List name, birthdate, sex, relationship of all children, and whether they live at home with you.

NAME

BIRTHDATE

SEX

RELATIONSHIP

AT HOME?

Yes
No

NAME

BIRTHDATE

SEX

RELATIONSHIP

AT HOME?

Yes
No

NAME

BIRTHDATE

SEX

RELATIONSHIP

AT HOME?

Yes
No

NAME

BIRTHDATE

SEX

RELATIONSHIP

AT HOME?

Yes
No

Who is coming for counseling?

Any prior counseling?

Yes
No

If yes, when?

Where?

With whom?

Why?

Are you, or another family member, currently seeing a psychiatrist or another counselor?

Yes
No

If so, what family member?

Name of counselor

For what purpose?

Person to contact in emergency (name, relationship, phone, address).

PLEASE FILL OUT THE FOLLOWING INFORMATION AS IT APPLIES TO THE CLIENT

State the nature of the problem in your own words.

What is your most difficult relationship right now?

What is your difficult emotion right now?

E. CRISIS INFORMATION:

Any current suicidal thoughts, feelings or actions?

Yes
No

If yes, explain

Any current homicidal or assaultive thoughts or feelings, or anger-control problems?

Yes
No

If yes, explain

Any past problems, hospitalizations, or jailings for suicidal or assaultive behavior?

Yes
No

If yes, explain

Any current threats of significant loss or harm (illness, divorce, custody, job loss, etc.)?

Yes
No

If yes, explain

F. MEDICAL INFORMATION:

Doctor’s name, address and phone

Are you presently taking any medication?

Yes
No

If so, what?

For what purpose?

Any problems with

eating
sleeping
chronic pain
recent weight changes

Describe any answers checked above

Any other medical problems?

Have you or a family member ever been hospitalized for mental or emotional illness?

Yes
No

If yes, please explain – dates, where, reason:

G. Common problems/symptom checklist.

Fill in: 0 –none, 1 – mild, 2 – moderate, 3 – severe

Marriage

divorce/separation

alcohol/drugs

God/faith

pre-marital

child custody

being single

church/ministry

other addictions

disabled

grief/loss

past hurts

sexual issues

work/career

depression

family

codependency

school/learning

fear/anxiety

intimacy

children

parents

money/budgeting

anger control

communication

aging/dependency

loneliness

self-esteem

in-laws

weight control

mood swings

stress control

Other (specify)

Who referred you to us? (Name, relationship and phone number)

Family Impact Centers

Home
About Us
Services
Men's Ministries
Women's Ministries
Community Support
News & Events
Single Women of Hope
Fall Celebration 2018
Ways to Give
Contact
Intake Form

Family Impact Center

735 N. Grand Avenue., Fowlerville, MI 48836

Family Impact Wellness Center

9430 W. Grand River Ave., Fowlerville, MI 48836

(517) 223-4428

(517) 223-4438

info@familyimpactcenters.com

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