SOUL CARE INTAKE FORM
ATTN: Please fill out 1 form for each counseling participant (e.g., 1 form for individual, 2 forms for couples) SOUL CARE INTAKE FORM Date__________ Client Name_______________________________________Date of Birth_________age___ Name of Person filling out form (if different)________________________________________ Client Address___________________________________City/Zip______________________ Best number to reach you? ____________________ Name of Contact______________ Second best contact number?___________________ Name of Contact_____________ Email___________________________ Is it okay to leave a message at the above phone numbers if needed?______________ How did you hear about Soul Care? _________________________________________ What times are you available? (Monday-Sunday) ______________________________ Fee____________ Soul Care’s counseling fee is $50 dollars per session unless proof of lower income can be provided with the intake. If your gross income is less than $4000 per month please circle your income bracket and attach a copy of your most recent pay stub. We are only able to accept cash or check. Income Bracket: Per session amount: $4000+ $50 $3000-$3900 $40 $2500-$2999 $30 $1500-$2499 $20 Under $1499 $10 Page 1 of 6 3/28/06 PERSONAL DATA INVENTORY Please describe in detail what brings you into counseling: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Services desired: Financial situation: (Please check all that apply) (Please check all that apply) □ Individual counseling □ Marital/Couples Counseling □ Family Counseling □ □ □ □ □ Marital Status: (Please check all that apply) □ □ □ □ □ □ □ □ □ Single, never married Engaged_____ months Married for _____ years Divorced for _____ years Separated for _____years Divorce in process _____ months Live-in for _____ years _____ prior marriages (self) ______prior marriages (partner) Social support system: (Please check all that apply) □ □ □ □ □ □ Supportive network Few friends Substance-use-based friends No friends Distant from family Involved in church fellowship Military history: Employment: (Please check all that apply) □ □ □ □ □ □ □ No current financial problems Large indebtedness Poverty or below-poverty income Impulsive spending Relationship conflicts over finances Employed and satisfied Employed and dissatisfied Unemployed Coworker conflicts Supervisor conflicts Unstable work history Disabled:______________ (Please check all that apply) □ Never in military □ Served in military-no incident □ Served in military with incident ________________________ Legal History: (Please check all that apply) □ □ □ □ □ □ □ No legal problems Now on parole/probation Arrest(s) not substance-related Arrest(s) substance-related Court ordered this treatment Other________________________ Jail/prison _______time(s) Total time served:_______ Page 2 of 6 3/28/06 Family: Household members other than yourself and spouse (What is your relation to the members, i.e., Biological child, adopted child, foster child, step-child, spouse’s child, brother, sister, parent or friend.) Name__________________ Relationship________________ Age__________ Name__________________ Relationship________________ Age__________ Name__________________ Relationship________________ Age__________ Childhood family experience: (Please check all that apply) □ □ □ □ □ Outstanding home environment Normal home environment Chaotic home environment Witnessed physical/verbal/sexual abuse toward others Experienced physical/verbal/sexual abuse from others Psychiatric/Health History: Have you had any prior counseling/psychotherapy?________ If yes, on ___ occasions. Longest treatment by ________________ for ___sessions, from ____/____ to ___/___. Have you had any prior inpatient treatment for a psychiatric, emotional, or substance use disorder?______ If yes, on ___occasions. Longest treatment at _______________________ from ___/___ to ___/___ Prior or current psychotropic medication usage?_______ If yes, Medication________________________ Dosage_____________ Start date______ End date____________ Date of your last complete physical exam ___________________ Are you presently being treated for any health problems? ______If yes, what________________________________ Please list all medication you are currently taking (give dosage and reason) ______________________________________________________________________________ ______________________________________________________________________________ Page 3 of 6 3/28/06 Substance Use History: (please check all that apply) Substance Use Status: □ No history of abuse □ Current Use □ Active abuse □ Past use □ Past abuse Current substances used: □ Alcohol □ Caffeine □ Marijuana □ Nicotine □ Prescription □ Other drugs Treatment history: □ Outpatient (date_______) □ Inpatient (date________) □ 12-step program (date_______) □ Stopped on own (date_______) □ Other_______________________ Family alcohol/drug abuse history: □ Parent(s) □ Grandparent(s) □ Sibling(s) □ Uncle(s)/Aunt(s) □ Spouse/significant other □ Children □ Other_________________ Target Symptoms Please indicate all symptoms that are experienced by marking the level that best describes their severity. Circle one level for each applicable symptom, and indicate how long the symptom has been present. Depressed Mood None Mild Moderate Severe Duration Fatigue/Low energy None Mild Moderate Severe Duration Hopelessness/Helplessness None Mild Moderate Severe Duration Elevated Mood None Mild Moderate Severe Duration Body Complaints (like headaches) None Mild Moderate Severe Duration Suicidal Ideas None Mild Moderate Severe Duration Weight Gain/Loss None Mild Moderate Severe Duration Anxiety None Mild Moderate Severe Duration Lack of Concentration None Mild Moderate Severe Duration Sleep Disturbance None Mild Moderate Severe Duration Panic None Mild Moderate Severe Duration Phobias None Mild Moderate Severe Duration Obsessions/Compulsions None Mild Moderate Severe Duration Poor Impulse Control (Temper) None Mild Moderate Severe Duration Violence, Anti-social Behavior None Mild Moderate Severe Duration Unusual Energy None Mild Moderate Severe Duration Racing Thoughts None Mild Moderate Severe Duration Disorganized Thinking None Mild Moderate Severe Duration Bizarre Ideation/Impulses None Mild Moderate Severe Duration Homicidal Impulses None Mild Moderate Severe Duration Bingeing/Purging None Mild Moderate Severe Duration Mood Swings None Mild Moderate Severe Duration Irritability None Mild Moderate Severe Duration Delusions None Mild Moderate Severe Duration Hallucinations None Mild Moderate Severe Duration Conduct Problems None Mild Moderate Severe Duration Social isolation None Mild Moderate Severe Duration Page 4 of 6 3/28/06 Worthlessness Hyperactivity Dissociative states Aggressive Behavior Alcohol/Chemical Over Use None None None None None Mild Mild Mild Mild Mild Moderate Moderate Moderate Moderate Moderate Severe Severe Severe Severe Severe Duration Duration Duration Duration Duration Contributing Factors Please circle how these aspects of your life affect, cause, or relate to any of your symptoms Marriage/Relationship No Effect Mild Moderate Severe Family No Effect Mild Moderate Severe Job/School Performance No Effect Mild Moderate Severe Friendships No Effect Mild Moderate Severe Hobbies No Effect Mild Moderate Severe Physical Health No Effect Mild Moderate Severe Sexual Functioning No Effect Mild Moderate Severe Spirituality No Effect Mild Moderate Severe Concerns Please indicate what concerns you have by circling the severity of each concern listed below. Bereavement Mild Moderate Severe Comment Anger with God Mild Moderate Severe Comment Fear Mild Moderate Severe Comment Guilt Mild Moderate Severe Comment Homosexuality Mild Moderate Severe Comment Infidelity of self Mild Moderate Severe Comment Infidelity of spouse Mild Moderate Severe Comment Insecurity Mild Moderate Severe Comment Loss of faith in God Mild Moderate Severe Comment Loss of love Mild Moderate Severe Comment Legal Problems Mild Moderate Severe Comment Relationship with Mild Moderate Severe Comment Parents Relationship with Mild Moderate Severe Comment superiors Religious doubts or Mild Moderate Severe Comment fears Intense anger Mild Moderate Severe Comment Loss of faith in others Mild Moderate Severe Comment Loss of meaning Mild Moderate Severe Comment Nervousness Mild Moderate Severe Comment Eating Habits Mild Moderate Severe Comment Financial problems Mild Moderate Severe Comment Troublesome dreams Mild Moderate Severe Comment Vocational direction Mild Moderate Severe Comment Relationship with Mild Moderate Severe Comment children Despair Mild Moderate Severe Comment Loneliness Mild Moderate Severe Comment Loss of hope Mild Moderate Severe Comment Loss of self-respect Mild Moderate Severe Comment Page 5 of 6 3/28/06 Physical trauma victim Sexual abuse trauma victim Physical Trauma Perpetrator Sexual abuse Perpetrator Self-Mutilation Self-doubt Mild Mild Moderate Moderate Severe Severe Comment Comment Mild Moderate Severe Comment Mild Mild Mild Moderate Moderate Moderate Severe Severe Severe Comment Comment Comment Please return to Soul Care either by: 1) Scanning the completed form and emailing it to [email protected] 2) Mailing the form in a sealed envelope, addressed to Soul Care, to 3735 Placer Corporate Dr. Rocklin, CA 95765 3) Dropping the completed form off in a sealed envelope in either the main church or Soul Care offices. ATTN: Please be advised that the counseling fee will be $50 per session unless a proof of income is attached to this form. Intakes are assigned to therapists weekly on Wednesdays at noon. Page 6 of 6 3/28/06
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