Adult Intake Form Step 1 of 3 33% Name* First Last PhoneEmail 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?NameAgeRelationship 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:MedicationDosageCondition *If you have not Read and Electronically Signed the Informed Consent Documents, please do so now. Sign Form