Date: _____________

2nd Star Counseling, LLC

Kathryn Raley, LPCC
Secondary Education, B.S.
MA Community Counseling, Regis University
Certificate Counseling Youth and Adolescents
Certificate, Transpersonal Counseling
NCC

Denver and Lafayette

Colorado, 80026

720-515-8796

Confidential Client Intake Form

Name: ______________________________________________________________________________________
Date of Birth: ____________

Age: ________

Gender: ___________________________________________

Marital/Relational Status: __________________

Partner/Spouse Name: ________________________________

Children (Names and ages):_____________________________________________________________________

Others living in your home ______________________________________________________________________
Occupation: ______________________________ Highest Level of Education: ____________________________

CONTACT INFORMATION
Address: ______________________________ Phone number(s): _____________________________________
___________________________________

At which number(s) may I leave a message?________________

EMERGENCY CONTACT
Name: ________________________________ Relationship to you: __________________________________
Address: ______________________________ Phone: _____________________________________________
______________________________________ Alternate phone:______________________________________

EXPECTATIONS FOR THERAPY

What brings you to seek therapy now and what do you hope to gain?

_________________________________

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Date: _____________
What are your concerns about therapy? __________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
If you have had an experience with therapy in the past, can you briefly describe what worked for you or what you
didnt work? _________________________________________________________________________________
___________________________________________________________________________________________
PAST YEAR CHECKLIST
Only respond to those areas that apply to you. Please rate the level of distress these issues have caused you in the
past year:
0
None

1
Minor

2
Moderate

3
Considerable

4
Extreme

____Sleeping Too Much/Too Little

____Drug/Alcohol (self or other)

____Financial Concerns

____Eating Too Much/Too Little

____Loneliness

____Legal Difficulties

____Mood Swings

____Caring for others

____Major Life Transition

____Angry Outbursts

____Distance from Loved Ones

____Gender Identity Conflict

____Depression

____Death/Major Loss

____Sexual Identity Conflict

____Repetitive Behaviors

____Past trauma

____Cultural Concerns

____Anxiety/Fear

____Health Problems

____Religious Conflicts

____Lack of Energy

____Sexual Problems

____Experienced Discrimination

____Hear/See things others cannot

____Relationship Problems

____Suicidal Thoughts/Actions

____Concerns regarding family

____Physical/Emotion/Sexual abuse

____Education/Work Concerns

MEDICAL AND MENTAL HEALTH TREATMENT INFORMATION

Please describe your physical and mental health including significant hospitalizations, illnesses, and/or
medications. ________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Are you currently receiving other mental health services or medical treatments?
___________________________________________________________________________________________
___________________________________________________________________________________________

Date: _____________
SUBSTANCE USE
Do you currently use tobacco, alcohol, or other drugs? _____________________________________________
Substance

How much and how often?

Past Use

_____________

_________________________________

______________________

_____________

_________________________________

______________________

_____________

_________________________________

______________________

_____________

_________________________________

______________________

(If applicable) When you used the most, how much did you use? ________________________________________
___________________________________________________________________________________________
Past substance abuse treatment? ________________________________________________________________

LEGAL HISTORY
Are you involved in the legal system or have you had significant legal issues in the past?
___________________________________________________________________________________________
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FAMILY INFORMATION
Please give me a brief family history. Describe family of origin and your current family dynamics:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

RELATIONSHIPS WITH OTHERS

Please describe the important people in your life and the quality of these relationships:
___________________________________________________________________________________________

Date: _____________
___________________________________________________________________________________________
___________________________________________________________________________________________
Have you now or ever experienced violence, abuse, or threatening behavior in a
relationship?_________________________________________________________________________________
TRAUMA HISTORY
Please list any past traumatic experiences you have had (including but not limited to childhood abuse, military
combat, assault, natural disasters, life threatening illness).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
STRENGTHS AND RESOURCES
What helps you to make it through difficult times?
___________________________________________________________________________________________
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Who can you count on for support in times of need? _________________________________________________
___________________________________________________________________________________________
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What gives you personal enjoyment?
___________________________________________________________________________________________
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Tell me about special skills or abilities that you have.
___________________________________________________________________________________________
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Date: _____________
What communities are you a part of?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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Do you have religious practices or spiritual beliefs that are important to you?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Is there anything else you think I should I know? _____________________________________________________
___________________________________________________________________________________________
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