The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM
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1 The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM Personal Information Date: Name: Phone #: Cell #: May we leave a message on these numbers?: Best time to reach me is: Address: City Zip Occupation: Gender: Birthdate: Age: Address: Marital Status: Single Engaged Married Separated Divorced Widowed Education: (Highest Degree Completed): Other Education: The Basic Problem As You Understand It: Briefly complete the following (please use the back of this form if necessary): 1. In your own words, please describe the current problem. 2. What have you done about it? 3. What are your expectations in coming here? 4. What led you to seek help now? 5. As you see yourself, what kind of person are you? Describe yourself. 6. Is there any other info we should know? 1
2 INFORMATION ABOUR PRIOR COUNSELING Have you had counseling before? Yes No Counselor Name (s) Dates: To-From Medication Outcome and Diagnosis Prescribed May we contact your counselor (s)? Please initial INFORMATION ABOUT PERSONAL HABITS AND HEALTH Approximately how many hours of sleep to you get each night? When do you normally: Go to bed? Fall asleep? Wake up? Get out of bed? If there is a length of time between going to bed and falling asleep, what do you do during that time? If there is a length of time between waking up and getting out of bed, what do you during that time? Describe any recent changes in sleep habits? State of health: Very Good Good Average Declining Other Date of last medical examination: Results: Physicians Name: Address: Are you presently taking medications? No Yes What? Dosage? For what reason do you take this medication? Have you used drugs for other than medical purposes? No Yes When? What? Amount/Dosages? Do you drink alcoholic beverages? No Yes How often? How much? Have you ever been arrested? No Yes What was the outcome? List all important present or past illnesses, injuries or handicaps Approximate weight Weight changes recently: Lost Gained 2
3 MARRIAGE AND FAMILY INFORMATION Name of spouse: Address: City Zip Phone #: Business Phone #: Occupation: Your spouses age: Education: (Highest Degree): Religion: Is spouse willing to come with you? No Yes Have not asked yet? Not certain Are you currently separated? No Yes Since when? Have you ever been separated in the current marriage? No Yes No. of times Has either of you ever filed for divorce? No Yes When? Who? Date of marriage: Your ages when married: Husband Wife How long did you know your spouse before marriage? Length of steady dating with spouse: Length of engagment: Have you been married before? No Yes If yes, how many times? Husband Wife If you or your spouse were married before, how did the marriage(s) end? Children s Living? Education Marital **PM Names Ages Gender Yes No In years Status **Check this column if child is by previous marriage If you were raised by anyone other than your parents, briefly explain: No. of older: Brothers Sisters No. of younger: Brothers Sisters 3
4 Concerns Please circle any symptom that applies to you or would help you to describe a problem you are having. A. Physical Concerns 1. Change in: 3. Recent History of: Sleep Nausea & Vomiting Skin rash Appetite Diarrhea Miscarriage Physical Energy Fever, Chills, Sweats Abortion General Health Chest Pain Seizure(s) Weight Shortness of breath Numbness Interest in Activity Palpitations (pounding heart) Paralysis Rapid breathing Dizziness 2. Increased use of: Sever headache Tingling Alcohol Head injury Blackouts Drugs Loss of consciousness Delirium tremors Pain Relievers Loss of memory Flashbacks Antacids Change in vision Illness Laxatives Difficulty in speech Hospitalization Diet Pills Loss of balance Infection Sleeping Pills Swollen joints Bleeding B. Physical Concerns 1. Thoughts of: 3. Feelings of: 4. Fear of: Suicide Anxiety Loss of control Harming-self Depression Death Harming others Dread Being Alone Despair/Hopelessness Objects 2. Experiences of: Low self-worth Animals Vivid Dreams/nightmares Jealousy Places Decrease need for sleep Tension Situations Hearing voices Rage Being possessed Seeing visions Persecution Being insane Being out of body Boredom Cancer Thought control Loneliness AIDS Racing thoughts Guilt Exposure High energy Punishment C. Social/Occupational Concerns 1. Conflict with: 3. Problem with: Spouse Finances Family Member Legal authorities Child Job Friend/peer School Work supervisor 2. Victim of: Bad accident Persecution War injury Rape Discrimination Natural Disaster Physical Abuse Disfigurement Witness to violence/death Sexual abuse Vandalism Cult group/practice Verbal abuse Emotional Abuse Slander Violent crime Spouse or child abuse Malpractice Harassment Other: 4
5 Consent to Counseling Form Our Goal Our goal at G.R.A.C.E. is to provide counseling that is based on biblical principles to help you become all you want to be. We not only look to relieve symptoms and meet challenges, but help you through a variety of techniques. Confidentiality Confidentiality is of paramount important to us at G.R.A.C.E. What you share in the counselor s office is completely confidential and will not be shared. However, there are a couple of scenarios that would warrant that confidentiality being broken. We are obligated by law to report abuse of any kind. Also, if you make threats against another person G.R.A.C.E. is obligated to contact the authorities and/or the person who the threat is made against. If it is deemed that you are a suicide threat the proper authorities will also be contacted as well for your safety. Your case may be discussed with another counselor without revealing names so as so ensure you receive the best possible care. Professionalism-Counselors at G.R.A.C.E. are professional in their approach to counseling and abide by the Code of Ethics of the American Association of Christian Counselor and the American Counseling Association. Jon is a Board Certified Pastoral Counselor with the Georgia Board of Examiners of Christian Counselors and Therapist. This is not the Georgia Composite Board that credentials professional counselors. Jon counsels from a Christian perspective and utilizes a variety of techniques to help you to grow in your personal and professional life. By signing this from I give G.R.A.C.E. permission to counsel me. Signed Date 5
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Declaration of Practices and Procedures
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11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
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Parents Names (If Client is a Minor) Client Information Sheet Client s Last Name First M.I.. Social Security No. Date of Birth: Age Sex M / F Home Phone No.( ) Education Level: Marital Status: Home Address:
PATIENT REGISTRATION FORM
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