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CLIENT INTAKE

Please provide the following information and answer the questions below. When not applicable, please put "N/A." Please note: information you provide here is protected as confidential.

Client Full Name:

Preferred Name: Birth Date:

Name of parent/guardian (if under 18 years):

Marital Status: Never Married Domestic Partnership Married Separated Divorced Widowed

Please list any children and their ages:

Address:

(City) (State) (Zip)

Home Phone: May we leave a message?YesNo

Cell/Other Phone: May we leave a message? Yes No

E-mail: May we email you? Yes No

Emergency Contact: Phone:

How were you referred to us: Is there any additional information PathLight Counseling should know about you?

GENERAL HEALTH AND MENTAL HEALTH INFORMATION:

Have you previously received any type of mental health services (therapy, psychiatric services, etc.)? Yes No

If yes, previous therapist/practitioner(s) and dates:

Are you currently taking any prescription medication? Yes No

Please list:

Have you ever been prescribed psychiatric medication? Yes No

If yes, Please list and provide dates:

How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise to you participate in?

Please list any difficulties you experience with your appetite or eating patterns:

Are you currently experiencing overwhelming sadness, grief, or depression? Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks, or do you have any phobias? Yes No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain? Yes No

If yes, please describe:

Do you drink alcohol more than once a week? Yes No
How often do you engage recreational drug use? Daily Weekly Monthly Infrequently Never
Are you currently in a romantic relationship? Yes No

If yes, for how long?

On a scale of 1-10 (1=unhealthy/unsatisfying; 10=healthy/satisfying) how would you rate your relationship? Why?

What significant life changes or stressful events have you experienced recently:

FAMILY MENTAL HEALTH HISTORY:

In the section below, identify if there is a family history of any of the following. Check all that apply. If checked, please indicate the family member(s) relationship to you in the space provided (father, grandmother, uncle, etc.).

	Check all that apply	Family Member
Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts

ADDITIONAL INFORMATION:

1. Are you currently employed? Yes No
  If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your work or work environment?

1. Do you consider yourself to be spiritual or religious? Yes No
  If yes, describe your faith or belief:

1. What do you consider to be some of your strengths?
2. What do you consider to be some of your weaknesses?
3. What would you like to accomplish through your time in therapy?

I, (client or legal guardian) authorize PathLight Counseling, LLC or any

holder of medical information about me to release to my insurance company or its representative, any information needed concerning the examination or treatment rendered to me that is necessary to process the insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to be paid directly PathLight Counseling, LLC in such amount as my benefits allow. This authorization is effective until terminated in writing by the client or their guardian. Your signature below also indicates that you have read the Consent for Treatment and HIPPA agreement and agree to the terms.

Print & Sign: Parent(s)/Guardian(s)PATIENT (or PARENTS/GUARDIANS, IF PATIENT IS A MINOR)

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Your legal name

Your email address

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February 5, 2025 5:04 pm -02

CLIENT INTAKE Uploaded by Britt Parramore - info@pathlightga.com IP 162.239.100.54