SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)
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1 Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC Mobile: Fax: Couples / Marriage Counseling Intake Form Today s Date: SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY Name: (Last) (First) (Middle Initial) Birth Date: / / Age: Gender: Male Female Ethnicity: Asian Hispanic / Latino African-American Caucasian Other: STUDENT / EMPLOYMENT STATUS: Full-Time Employed Part-Time Employed Homemaker / Caretaker Legally Disabled Unemployed Retired Full-Time Student Part-Time Student Active Volunteer Length of Employment: Retirement / Unemployment Date: School and Grade or Major / Degree: Employer Name and Position: PHYSICIAN INFORMATION: Referring Physician: Phone: Address: City: State: Zip Code: Primary Care Physician (PCP): Phone: Address: City: State: Zip Code: CONTACT INFORMATION: Mailing Address: Physical Address (If Different): May I send mail to the above mailing address? Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 1 of 9
2 Telephone Numbers / Address (Please provide only numbers at which you give me permission to call you): Home: May I leave a message? Work: May I leave a message? Cell: May I leave a message? *: May I you? *Please be aware that might not be confidential. Name of Contact Person in Case of Emergency: Telephone #: Relationship: MENTAL HEALTH HISTORY: 1. Are you currently receiving psychotherapy elsewhere? 2. Have you ever had psychotherapy in the past? 3. If yes, previous therapist s name to either question above: When? Duration of treatment: Focus of treatment / presenting issue: 4. May I contact your primary care / referring physician to coordinate care? 5. In the past year, have you experienced any significant life changes, stressors, loss / grief, crisis, or trauma? If yes, please describe: 6. Have you ever experienced or are currently experiencing any of the following? Depression / feeling down / apathy Bipolar disorder / extreme mood swings Anxiety disorder / panic attacks (most recent occurrence): Phobias (phobia triggers): Sleep disturbance (e.g., difficulty falling or staying asleep, sleeping too much / too little, restlessness, etc.) Schizophrenia / hallucinations (auditory / visual) Unexplained memory lapses Alcohol / prescription medication / recreational drug abuse Frequent body complaints (e.g., achiness, persistent pain, migraine / tension headaches) Eating disorder (previous or current treatment): Body image issues Repetitive thoughts or behaviors (e.g., obsessions, rituals, etc.) Problems with concentration, focus, learning disability Trauma history / crisis Homicidal thoughts / acts of aggression Suicidal thoughts / attempts (last attempt / hospitalization): Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 2 of 9
3 FAMILY MENTAL HEALTH HISTORY: Has anyone in your family experienced difficulties with any of the following? Depression Bipolar disorder / extreme mood swings Anxiety disorder / pain attacks Phobias (phobia triggers): Sleep disturbance (e.g., difficulty falling or staying asleep, sleeping too much / too little, restlessness, etc.) Schizophrenia / hallucinations (auditory / visual) Unexplained memory lapses Alcohol / prescription medication / recreational drug abuse Frequent body complaints (e.g., achiness, persistent pain, migraine / tension headaches) Eating disorder Body image issues Repetitive thoughts or behaviors (e.g., obsessions, rituals, etc.) Problems with concentration, focus, learning disability Trauma history / crisis Homicidal thoughts / acts of aggression Suicide attempts / completion (family member): Medical Problems Active Problems / Health Concerns Date of Onset Surgical Procedures (Last 10 Years Only) Type of Surgery Date of Surgery Allergies Drug / Food Reaction Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 3 of 9
4 Current Medications Prescribed for Pain, Sleep Disturbance, Psychiatric Issues, Etc. Medication Dose Start Date Frequency Reason for Taking Prescribing Doctor Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 4 of 9
5 SECOND SPOUSE / PARTNER TO COMPLETE THIS SECTION SEPARATELY Name: (Last) (First) (Middle Initial) Birth Date: / / Age: Gender: Male Female Ethnicity: Asian Hispanic / Latino African-American Caucasian Other: STUDENT / EMPLOYMENT STATUS: Full-Time Employed Part-Time Employed Homemaker / Caretaker Legally Disabled Unemployed Retired Full-Time Student Part-Time Student Active Volunteer Length of Employment: Retirement / Unemployment Date: School and Grade or Major / Degree: Employer Name and Position: PHYSICIAN INFORMATION: Referring Physician: Phone: Address: City: State: Zip Code: Primary Care Physician (PCP): Phone: Address: City: State: Zip Code: CONTACT INFORMATION: Mailing Address: Physical Address (If Different): May I send mail to the above mailing address? Telephone Numbers / Address (Please provide only numbers at which you give me permission to call you): Home: May I leave a message? Work: May I leave a message? Cell: May I leave a message? *: May I you? *Please be aware that might not be confidential. Name of Contact Person in Case of Emergency: Telephone #: Relationship: Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 5 of 9
6 MENTAL HEALTH HISTORY: 1. Are you currently receiving psychotherapy elsewhere? 2. Have you ever had psychotherapy in the past? 3. If yes, previous therapist s name to either question above: When? Duration of treatment: Focus of treatment / presenting issue: 4. May I contact your primary care / referring physician to coordinate care? 5. In the past year, have you experienced any significant life changes, stressors, loss / grief, crisis, or trauma? If yes, please describe: 6. Have you ever experienced or are currently experiencing any of the following? Depression / feeling down / apathy Bipolar disorder / extreme mood swings Anxiety disorder / panic attacks (most recent occurrence): Phobias (phobia triggers): Sleep disturbance (e.g., difficulty falling or staying asleep, sleeping too much / too little, restlessness, etc.) Schizophrenia / hallucinations (auditory / visual) Unexplained memory lapses Alcohol / prescription medication / recreational drug abuse Frequent body complaints (e.g., achiness, persistent pain, migraine / tension headaches) Eating disorder (previous or current treatment): Body image issues Repetitive thoughts or behaviors (e.g., obsessions, rituals, etc.) Problems with concentration, focus, learning disability Trauma history / crisis Homicidal thoughts / acts of aggression Suicidal thoughts / attempts (last attempt / hospitalization): FAMILY MENTAL HEALTH HISTORY: Has anyone in your family experienced difficulties with any of the following? Depression Bipolar disorder / extreme mood swings Anxiety disorder / pain attacks Phobias (phobia triggers): Sleep disturbance (e.g., difficulty falling or staying asleep, sleeping too much / too little, restlessness, etc.) Schizophrenia / hallucinations (auditory / visual) Unexplained memory lapses Alcohol / prescription medication / recreational drug abuse Frequent body complaints (e.g., achiness, persistent pain, migraine / tension headaches) Eating disorder Body image issues Repetitive thoughts or behaviors (e.g., obsessions, rituals, etc.) Problems with concentration, focus, learning disability Trauma history / crisis Homicidal thoughts / acts of aggression Suicide attempts / completion (family member): Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 6 of 9
7 Medical Problems Active Problems / Health Concerns Date of Onset Surgical Procedures (Last 10 Years Only) Type of Surgery Date of Surgery Allergies Drug / Food Reaction Current Medications Prescribed for Pain, Sleep Disturbance, Psychiatric Issues, Etc. Medication Dose Start Date Frequency Reason for Taking Prescribing Doctor Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 7 of 9
8 ONE OR BOTH PARTNERS CAN COMPLETE THE REMAINING PAGES RELATIONSHIP STATUS: Single Dating Partnered / Significant Other Married Separated Divorced Widowed Duration of Relationship: Number of Children: Number of Children Still Residing in the Home: Child s Name Child s Age Biological / Adopted / Step / Foster / Other? Still Residing in the Home? Who Has Primary Custody or Where Is Child Residing? If married, has either of you threatened to separate or divorce as a result of the current relationship problems? Have either you or your spouse consulted with a lawyer about divorce? REASON FOR SEEKING COUPLES / MARRIAGE COUNSELING: Please check any of the reasons listed below that resulted in your request for couples / marriage counseling: Pre-marital counseling Relationship enhancement Depression or anxiety Communication difficulties / arguments Physical intimacy issues / sexual relations Parenting issues / parenting conflict Partner values conflict Conflict with in-laws / partner s family Life transition / diminished health concerns Role conflict / responsibilities Poor work-life balance / little time together Sexual orientation questions Alcohol / drug abuse Partner bullying / emotional abuse Physical abuse / restraint / acts of aggression Divorce / possible divorce counseling Other: Other: Other: Other: What would you like to gain from couples / marriage counseling? As a couple, what are your goals or specific issues you hope to address? Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 8 of 9
9 INSURANCE INFORMATION / AUTHORIZATION OF PAYMENT OF SERVICES Insurance Information: Insurance Carrier: Insured s Name: Plan Name: Insured s ID Number: Insured s Social Security Number: Insured s Date of Birth: Insured s Employer Name: Insured s Address if Different from Client: Driver s License Number: State Issued: Please remember that I will be considered an out-of-network provider should you wish to use your insurance for reimbursement of payment for services. Credit Card Information and Authorization for Payment: I,, authorize Katherine E. Walker, PhD, LPC, NCC, BCIA-C to charge the below-referenced credit card when I have not cancelled my scheduled appointment within 24 hours or fail to show for my scheduled appointment time. I understand that this also includes any appointment that is considered a client no-show or for any balance due that is owed due to my insurance company not covering services. Type of Card: MASTERCARD VISA DISCOVER AMERICAN EXPRESS Account Holder Name Listed on Credit Card: Credit Card Number (Please Include Dashes): Credit Card Expiration Date: Complete Billing Address for This Credit Card: Authorized Card Holder Signature Date Couples / Marriage Counseling Intake Form for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 9 of 9
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