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Our Counselors
Blog
Locations
About / Reviews
Get started
855-755-3797

Adult Intake Form

Step 1 of 3

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Name*
First Last
Phone
Email

How can we help?
Briefly identify what brings you into counseling.*
Briefly describe the history and development of your concern from onset to the present.*
What are your goals for counseling - what do you hope to accomplish?*
Have you been to counseling before?*
- Yes
- No
Briefly describe your previous experiences with counseling.
Who do you live with?
Name Age Relationship to You

What are your current stresses?
Please indicate areas of stress in your life.
- Marriage/Home
- Children/Parents
- Work/School
- Financial
- Spiritual
- Social
- Sexual
- Other
Please briefly describe the areas of stress marked above.
Symptom Checklist (please check all that apply):
- I am dissatisfied with my life and want to change.
- I am dissatisfied with the current state of my family life.
- I am dissatisfied in my relationship with my spouse or significant other.
- I am dissatisfied with, confused about or have questions regarding the sexual part of my life.
- I am dissatisfied with my interpersonal relationships in general.
- I am dissatisfied with my body.
- In the past 3 months I have thought about how I could end my life.
I have recently experienced:
- moodiness
- unusual anger or irritability
- anxious feelings
- loneliness
- change in sex drive
- change of appetite
- unusual fatigue
- difficulty sleeping
- nightmares
- resentment
- stomach trouble
- bowel disturbances
- racing thoughts
- apathy/hopelessness
- mental confusion or disorientation
- decreased energy of motivation
- feelings of helplessness
- feelings of sadness, loss, or grief
- inferiority feelings
In the last few months, in order to feel better about my life, I have done the following:
- binge eating
- drank alcohol
- used illegal drugs
- misused prescribed drugs
- ignored my normal responsibilities
- refused to get out of bed or do normal hygiene
- isolated myself from people
- constantly surrounded myself with people
- worked more than usual
- used pornography or erotic material
- acted sexually in an unusual way for me
- harmed myself by cutting, burning, etc.
In my lifetime I have experienced:
- the loss of a loved one
- a traumatic event
- sexual abuse or assault
- physical abuse or assault
- mental or verbal abuse
- the death of a child
- an abortion
- divorce of my parents
- divorce of my own
- the loss of someone by suicide
- an addictive habit
- living with someone who was/is addicted
- abandonment by important people to me
- exploitation by important people to me
- being unloved by important people to me
- be fired from a job
- something else significant to me (please describe below)
Please specify what has occurred:*
Current Medications:
Medication Dosage Condition

*If you have not Read and Electronically Signed the Informed Consent Documents, please do so now. Sign Form

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2131 S Eastgate Ave
Springfield, MO 65809
855-593-4357

Locations

MyCounselor Springfield, MO | Christian Counseling
2131 S Eastgate Ave, Springfield, MO 65809

MyCounselor Kansas City, MO | Christian Counseling
6501 E Commerce Avenue, Kansas City, MO 64120 Suite 140

MyCounselor Columbia, MO | Christian Counseling
3610 Buttonwood Dr, Ste 200, Columbia, MO 65201

MyCounselor Denver – Centennial, CO | Christian Counseling
4901 E Dry Creek Rd, Ste G20, Centennial, CO 80122

MyCounselor Pensacola – Navarre, FL | Christian Counseling
7552 Navarre Parkway, Unit 62, Navarre, FL 32566

MyCounselor Nashville, TN | Christian Counseling
5205 Maryland Way, Suite 310, Brentwood, TN 37027

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