MaryJane Wilt       ~       Whole Heart Counseling Services
212 NE 80th Ave, Portland, OR, 97213; On-Line                            971.242.9322 (tel)

Intake Form

Date _______________

Last Name __________________________ First Name __________________________

Address _________________________________________________________________

City ___________________________  State _________________  Zip _____________

Home Phone _____________________  Work Phone/Cell __________________________

Gender (M/F) ___________  DOB ________________  SS# ___________________

Is it acceptable to call you at home?         Yes   No

If no, then how may I contact you? ______________________________________________

At what phone number may I leave a message? _______________________________________

Are you currently under medical care?         Yes         No

If yes, then please explain/describe. ______________________________________________

_______________________________________________________________________

Name of personal physician and phone number: _______________________________________

Are you currently taking prescribed medications?         Yes   No

If yes, then please explain/describe. ______________________________________________

_______________________________________________________________________

List any psychiatric/mental health medications you have taken. ____________________________

_______________________________________________________________________

Have you been under the care of a psychiatrist, psychologist, or counselor?    Yes      No

If yes, please give the name, date, and location of the therapy, and briefly explain the nature of the problem that required attention. _______________________________________________________________

____________________________________________________________________________

 

Please circle any of the following struggles that pertain to you:

Anxiety, Depression, Fears/Phobias, Sexual Problems, Suicidal Thoughts, Separation/Divorce, Relationships, Finances, Drug/Alcohol Use, Career Choices, Anger, Self-Control, Unhappiness, Insomnia, Religious Matters, Work/Stress, Health Problems, Cutting/Self-Mutilation, Thought Patterns, Other: __________________________________________________________

In case of an emergency, notify:

 

Name: __________________________________________________________________

Address: ________________________________________________________________

Work Phone: _____________________________________________________________

Home Phone: _____________________________________________________________

Relationship: ______________________________________________________________

 

OR

 

Name: __________________________________________________________________

Address: ________________________________________________________________

Work Phone: _____________________________________________________________

Home Phone: _____________________________________________________________

Relationship: ______________________________________________________________

 

 

 

Client Signature: __________________________________________________________

 

Client Signature: __________________________________________________________