Karis Counselling Services Intake Form

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Thank you for taking the time to complete this intake form.  I will get the results directly once you click the Send button.

Date:

Name:

Gender:

Age:

Mailing Address:

Phone:

(home)
(work)
(cell)

Email:

Skype:


May Karis Counselling Services Contact You At.....
 Home? Work? On your cell phone?

May Karis Counselling Services ....
 Leave a phone message? Contact by email? Contact with a text? Contact by mail? Contact by Skype?

Occupation:

Education:

Religion:

Medical Information:

Last Checkup:

Present Health:

Are you currently taking any prescription medications?
 Yes No

If yes.....

Type:

Dosage:

Purpose of medication:

How long have you been taking them?

Do you find that they are helping?
 Yes No

Why/Why not?

Have you taken any prescription medications in the past?
 Yes No

If yes.....

Type:

When taken:

Why not taking now:


Problems with Coping:

Are you currently struggling with any form of sleeping problems?
 Yes No

How?

Are you currently struggling with any eating problems?
 Yes No

How?

Are you currently struggling with any self-harming behavior (i.e. cutting?)
 Yes No

How?

Do you currently feel suicidal?
 Yes No

How?

Have you ever attempted suicide?
 Yes No

When?

How?


Marital Status / Family Information:

Check what applies to you....

 Single Divorced Married Common Law Separated Remarried Widowed

How long have you been married/common law?

If separated, how long?

If divorced, how long?

How many children do you have from your present marriage/common law?

How many children do you have from any previous relationship(s)?

Have you ever had a miscarriage?
 Yes No

If yes, when?

Have you ever had an abortion?
 Yes No

If yes, when?

First name, age, and relationship of people you currently live with:

First name, age, and relationship of other immediate family members that do not live with you:


Previous Counselling

Have you received previous counselling?
 Yes No

If yes...

Name of counsellor:

Agency:

Focus of sessions:

Did you find the counselling helpful?
 Yes No

Why or Why Not?

May Karis Counselling obtain records from this agency?
 Yes No


Present Counselling

Are you presently seeing another counsellor?
 Yes No

If yes...

Since when:

Name of counsellor:

Agency:

Focus of sessions:

Are you finding the counselling valuable?
 Yes No

Why or Why Not?

May Karis Counselling obtain records from this agency?
 Yes No


If married/common law/ in a relationship, please answer the following:

How do you feel your relationship is right now?
 Very rocky Poor Average Good Excellent

How do you feel you and your partner communicate?
 Not at all Just a little Not too bad Pretty good Excellent

Do any of these issues apply to your relationship ? Answer any that apply.

No/poor communication How Long?

Finances How long?

Sex How long?

Parenting How long?

In-laws How long?

Respect issues How long?

Affair How long?

Pornography How long?

Relational Abuse How long?

Emotional Adultery How long?

Mental Health Issues How long?

Spiritual Issues How long?

Other - please describe How long?

Are there any past/present experiences that have happened in your relationship that could be having an impact on your life situation right now?

On a scale of 1 to 10 how committed are you to staying in the relationship? (type the number in the box)


Personal Issues

Please indicate with a Yes or a No

Are you concerned about your alcohol or drug use?
 Yes No

Are others concerned about your alcohol or drug use?
 Yes No

Have you experienced negative consequences as a result of your use?
 Yes No

Do you or others have concerns about your gambling?
 Yes No

Please indicate with a check for any personal issues that apply to your life. Explain further below, if you feel you would like to.

 Abortion Adultery Alcohol use/abuse Divorce Drug Problems Eating disorder Emotional abuse Mental Health disorders Financial difficulties Health problems Legal issues Marriage Struggles Parent/Child Conflict Physical abuse Physical handicap Pornography Pregnancy Previous relationship that is affecting your present life Relational Abuse Sexual abuse Sexual behavior concerns Sexual Orientation concerns Sexually transmitted infection Spiritual Problems Other

Feel free to explain any of the above choices here:

How well do you feel you are handling life?
 Not well at all Not too bad Pretty good Excellent

How much hope do you have that counselling will better your life?
 Not at all A little bit Quite a bit Totally

How long have these struggles been affecting your life?
 Just recently 6 months 1 year Several years

What is/are the problem(s) for which you are seeking counselling for at this time?

What do you hope to accomplish through counselling?

How did you hear about Karis Counselling Services?
 Self Doctor Pastor Counsellor Focus on the Family Other


It is the goal of Karis Counselling Services to provide lasting support to our clients. We would appreciate your permission to have a short no-cost follow up call (or email) with you six months after our last session to confirm that the issues you came for to Karis Counselling Services are still resolved.

Please indicate your willingness by selecting one of the options below:

Thank you for taking the time to fill out this form.