Professional Documents
Culture Documents
Counseling Intake
Counseling Intake
2233
Counseling for Individuals, Couples, or Groups tiaharms@hotmail.com
Complete the following form to the best of your ability and bring with you to initial session. Use
reverse for additional writing space if necessary.
Client Name: Date:
3. Do you have any health concerns? Taking medications (If so, please list)?
7. Family of Origin Information (Describe parents, siblings, relatives; self as a child; significant
memories; primary relationships):
9. Religious/Spiritual Beliefs. Share any values in this area you think important for me to know:
Tia Harms LLC Ph. 503.559.2233
Counseling for Individuals, Couples, or Groups tiaharms@hotmail.com
10. Educational/Vocational Information (last grade completed; current job; history of job changes;
reasons for terminations; military):
11. Legal Information (protection orders, litigation (status/type), arrests, probation, custody, etc.):
12. Have you experienced depression? (If so, please describe symptoms):
Any planning?
14. Have you ever been in situations or relationships where you have felt verbally abused?
• Example: threats, name calling, controlling, isolating, overly jealous, limiting access to money,
friends, or family, etc.
Details:
15. Have you ever been in situations or relationships involving physical violence?
• Example: hit, shoved, restrained, choked, objects thrown at, kicked, sexual abuse, burned,
pinched, harmed with weapons or other objects, hair pulled, bitten, etc.
Details: