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Adult Intake Form

Please call 815-290-9711 BEFORE completing this form to ensure we can meet your needs and have an opening.

This form should be completed by the adult seeking counseling.

Did you speak to someone at Renew before completing this form?* Yes

First Name (as it appears on insurance card)*

Last Name*

Preferred Name

Date of Birth (MM/DD/YYYY)*

Street Address*

City*

State*

Zip Code*

Email*

Phone Number*

Is it OK to call and/or leave a message at this number? Yes No

Primary Care Physician

PCP Phone

Psychiatrist's Name

Psychiatrist's Phone

Describe why you are seeking counseling*

How long have you been experiencing this problem?*

Rate the intensity of this problem (1=mild 5=severe)* 1 2 3 4 5

How does the problem interfere with your day-to-day activities (work, sleep, eating, socializing, etc.)?*

Please check all the symptoms you have experienced in the past 3 months Sadness
Hopelessness
Sleep too much
Fatigued / No Energy
Poor Memory
No Motivation
Not interested in things I used to like
I think about death (my own or others)
I feel guilty often
Feel Worthless
No Need for Sleep
Talk too Fast
Irritable/Angry
Can't fall asleep
Too Much Energy
Not Hungry
Prefer Being Alone
Impulsive
Can't Concentrate
Restless
Suspicious
Hear things I'm not sure are there
See Odd Things
Have Special Powers
Repeated nightmares
Nervous
Fearful
Panic Attacks
Can't be in Crowds
Avoid People / Things
Anxiety
Easily Startled
Excessive Worry
Decreased Libido
Reoccuring Dreams
Increased Risky Behavior
I feel like I'm being watched
I feel like people are out to get me
I think about suicide
I've thought about how I could kill myself
Weight gain/loss when not trying
Feel like I can't calm down
I have a hard time living (working, bathing, doing anything)
Pounding heart
Sweating
Trembling / shaking
Short of breath
Choking / smothering feeling
Chest pain / discomfort
Nausea
Abdominal pain
Dizzy / light headed
Chills / hot flashes
Numbness / tingling
Ringing ears
Dry mouth
Muscle tension
I can't stop worrying
Extreme Fear of a certain object (snaked, spider, red things, etc.)
Fear of being separated from loved one
I have a hard time figuring out what's reality and what isn't
Fear I will catch a disease
Fear I have a disease (even after Dr. says I don't)
Spend time looking up symptoms to illness
Experienced a threat to my life (anytime, not just past 3 mo.)

Adult Intake Form

Who referred you for counseling services?

Have you received mental health services in the past?* Yes No

If so, whom did you see and when?

Have you ever been hospitalized for a mental health illness?* Yes No

If so, please list where and when

Are you currently on any prescribed medications for mental health?* Yes No

If so, please list each medication and dose

Please list any family history of mental illness (parents, aunts, grandparents, siblings, children, cousins, etc)

Please list any physical health problems you have experienced in the past year

Please list any regular medication you are on

Do you use tobacco?* Yes No

Would you or someone you know say you are having a problem with alcohol?* Yes No

Would you or someone you know say you are having a problem with pills or illegal drugs?* Yes No

Would you or someone you know say you are having a problem with other addictions?* Yes No

Would you or someone you know say you are having a problem with other addictions (gambling, shopping, porn, video games, etc.)?* Yes No

Is there a family history of addiction in your family?* Yes No

Are you adopted?* Yes No

Where did you grow up?*

Do you have siblings?* Yes No

If so, please list brother/sister and approximate ages

How would you describe your current relationship with your siblings?

Adult Intake Form

Are your parents living?* Yes No

If yes, how would you describe your relationship with your parents?

Are/were your parents divorced?* Yes No

Do you have a history of being abused emotionally, sexually, physically, or by neglect?* Yes No

If yes, please give any details you are willing to share

Highest grade completed

Are you currently employed?* Yes No

If so, where?

Job title

Have you ever served in the military?* Yes No

If yes, what branch?

If yes, when?

Honorable discharge? Yes No Not Applicable

If no, please share what you are willing

I am:* Married
Single
Divorced
Widowed
Living Together

If married or living together, how long?

How would you describe this relationship?

Do you have previous marriages?* Yes No

Do you have children?* Yes No

If yes, please list names and ages

Describe your relationship with your children

List everyone who currently lives with you

Please describe your spiritual life (believe in God or don't, am a Christian, attend church, believe in prayer, I'm not sure, etc.)

Is there anything else you would like us to know?

Adult Intake Form

Therapy at Renew Counseling is client centered and solution focused. Successful therapy follows a good plan including well thought out goals. Please take some time to think about what you want to work on during your sessions.

If you know some goals you want to address, please list them here

If you aren't sure, please look at the list below and choose anything you think might fit as a goal for you Setting boundaries
Expressing feelings appropriately
Managing anger
Dealing with Sadness
Sleeping Better
Learning how to relax
Decreasing Panic
Finding motivation again
Controlling myself better
Improving my self-esteem
Decrease / eliminate suicidal thoughts
Decrease unwanted thoughts
Building a relationship
Working on a relationship
Learning new parenting skills
Dealing with grief
Learning how to cope
Dealing with anxiety
Reducing alcohol/drug use
Improving a relationship
Improving my marriage
Learning to care for myself better
Reduce/stop harming myself
Feel less nervous

Answer this question as well as you can: If you woke up in the morning and your problems miraculously vanished, what would life be like? How would you know the problem was gone? What would you be doing? How would you be feeling?*

Your Adult Intake Form has been successfully submitted. Thank you.

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