Intake Tool
Form 2 of 4

Instructions

This entire packet must be completed by, or for, each individule participating in any service provided by PHH.
If this form is being filled out by an adult for a minor child or a dependent adult under the guardianship of the one filling out the form, the child or dependent adult's name and address are to be used in Section A and your information must be provided in Section B.
If you are simply assisting a person who cannot complete the form on their own, your information must be provided in Section B.

Partners Hope & Healing, Inc. (PHH)

General Counseling/Coaching Intake Packet

FORM 2

History

First Name

Last Name

Nickname

Birth Date

Section A

Employment & Education

Occupation

Number of years in current employment status

Section B

Family Dynamics

Total number of times married and/or cohabitating

Number of years in current relationship status

Details

Some of the information in this section may be used to evaluate your rate plan.

Number of biological and adopted children:

Number of step-children:

Number of adult children:

Number of adult children with whom you have a relationship today.

Number of biological and adopted children living with you:

Number of step-children living with you:

Number of children for whom you PAY child-suport

Number of children for whom you RECEIVE child-suport

Additional information regarding family and children

Section C

Medical Information

List all over the counter, prescription, and natural meications your are currently taking.

List all medical conditions for which you are currently being treated.

List all past surgical procedures and the year they were performed.

Have you ever been diagnosed wth a mental condition? Required

Yes

Explain the condition:

How was the condition treated?

Have you ever attended counseling or psychotherapy? Required

Yes

Why did you seek counseling or psychotherapy?:

What did you appreciate and dislike about the counseling you received.

Please tell us anything else about your medical, mental, or emotional past that you think we should know.

Section D

Family History

Select items that describe conditions of other people in your nuclear and extended family (spouse, mother or father, siblings, etc.)

Depression

Panic Attacks

Eating Disorder

OCD

Suicide

Trauma History

Domestic Violence

ADHD

Anxiety Disorders

Alcoholism

Sexual Abuse

Schizophrenia

Bipolar Disorder

Substance Abuse

Obesity

PTSD

Section E

Spiritual History

Tell us about your spirituality, religious practices, and memberships.

I testify that the information provided herein is honest and accurate to the best of my recollection.

Your Signature

After you click Submit, you will be taken to the next required intake form.

Intake Tool
Form 2 of 4

Instructions

Section A

Employment & Education

Section B

Family Dynamics

Section C

Medical Information

Section D

Family History

Select items that describe conditions of other people in your nuclear and extended family (spouse, mother or father, siblings, etc.)

Section E

Spiritual History

COUNSELING HOURS

ADDRESS

SUBSCRIBE TO JOIN
OUR MAILING LIST

Intake Tool Form 2 of 4

Instructions

Section A

Employment & Education

Section B

Family Dynamics

Section C

Medical Information

Section D

Family History

Select items that describe conditions of other people in your nuclear and extended family (spouse, mother or father, siblings, etc.)

Section E

Spiritual History

COUNSELING HOURS

ADDRESS

SUBSCRIBE TO JOIN OUR MAILING LIST

Intake Tool
Form 2 of 4

SUBSCRIBE TO JOIN
OUR MAILING LIST