Intake Forms - Alchemy Life Changers Inc.

Client's Full Name

First

Last

Client's Date of Birth

Client's Age

Gender

Marital Status

Mental Field Contact

Client's Email

Client's-(Guardian) Phone

Preferred Method of Contact

Client's Address

Emergency Contact

Full Name / Relationship / Phone Number

Reason for Seeking Counseling:

Please briefly describe your main concerns:

How long have these issues been affecting you?

Mental Health History

Have you received counseling before? ☐ Yes ☐ No If yes, when and for what issue(s)?

g

Have you ever been diagnosed with a mental health condition? ☐ Yes ☐ No If yes, please specify:

Field #34 (copy)

Are you currently taking any medications related to mental health? ☐ Yes ☐ No If yes, please list them:

Lifestyle & Well-Being:

Do you exercise regularly? ☐ Yes ☐ No

Field #34 (copy) (copy)

How many hours of sleep do you get per night?

Field #34 (copy) (copy) (copy)

Do you use alcohol, drugs, or tobacco? ☐ Yes ☐ No If yes, please describe:

Field #34 (copy) (copy) (copy) (copy)

Are you currently involved in a church or spiritual community? ☐ Yes ☐ No If yes, where?

Goals for Counseling:

What are your goals or what do you hope to achieve through counseling?

Consent & Agreement:

I understand that the information I provide is confidential and will be used for the purpose of counseling.
I consent to receive counseling services.
I have read and agree to the practice’s privacy policy and terms.