Adult Intake Form: Mental Health Coaching

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Adult Intake Form: Mental Health Coaching

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Adult Intake
Each adult meeting with the mental health coach must complete their own adult intake.
Name*
First Last
Phone*
Email*
Spouse Name:*
Spouse Email*

Tell us about you...
Date of Birth*
Month
Day
Year
Current Age*
Gender*
- Male
- Female
- Prefer Not To Share
How did you hear about MyCounselor?*
- Google or Other Search Engine
- Someone I trust recommended you
- Facebook or Other Social Media
- Other
Please share who referred you or how you heard about us...
Household Income*
*This information helps us apply for grants to provide scholarships to those in need.
- <$35k
- $35k-$70K
- $71k-$150k
- $151k-$200k
- >$200k
- I prefer not to share.

How can we help?
Briefly identify what brings you into coaching.*
What are your goals for coaching?*
I understand:*
- The payment method I provide MyCounselor.Online will be charged every 4 weeks starting the day I begin my membership for a total of 3 payments of $252.

- My membership includes four 45 minute units of mental health coaching every 4 weeks (total of 12 sessions)

- If I schedule more than 2 units in a 4-week billing cycle, I will be charged an additional session fee for each unit I schedule the day of the session.

- If I schedule any coaching sessions in additional to the 12 included, I will be charged an additional fee per session of $63

- I am not allowed to cancel my coaching membership and will complete all 3 payments of $252

- If I fail to give notice of cancelation or rescheduling at least 24 hours before my scheduled appointment, I am responsible for the full fee of my session. Appointments can be canceled or rescheduled by one of the following ways: using the link in your confirmation email or calling 855-593-4357 or emailing receptionist@mycounselor.online
I understand and agree.
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What are your current stresses?
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Please indicate areas of stress in your life.
- Marriage/Home
- Children/Parents
- Work/School
- Financial
- Spiritual
- Social
- Sexual
- Other
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Please briefly describe the areas of stress marked above.
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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.
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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
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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.
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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)
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Please specify what has occurred:*

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Current Medications:

Medication	Dosage	Condition

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Wait for Informed Consent Signature Page
After you click the "Submit" button below you will be redirected to the Informed Consent Document. You will need to read the document and sign at the bottom to complete your intake paperwork. **You can not meet with your counselor until you have signed the Informed Consent Document.**
Wait for Informed Consent Signature Page

After you click the "Submit" button below, you will be redirected to the Informed Consent Document. You will need to read the document and sign at the bottom to complete your intake paperwork. **You can not meet with your counselor until you have signed the Informed Consent Document.**
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We partner with influencers, employers, churches, universities, church planters, campus missions, and international missions sending organizations to make mental healthcare more accessible. Learn more about becoming a PARTNER or INFLUENCER.

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