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FAMILY COUNSELING ASSOCIATES, INC
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4425 MILITARY TRAIL SUITE 203
JUPITER FL 33458-4817
561-747-2775
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| Name: |
First Name
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Middle Name
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Last Name
DOB :
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| Nick Name :
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Legal Gender :
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Gender Identity :
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Address :
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City :
State :
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Zip :
Country :
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| Work Phone :
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May we call at work?
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Work Hours :
Copay :
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| Primary Insurance Information
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CarrierName :
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Other :
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Group # :
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Address :
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City :
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Policy # :
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State :
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Zip :
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Country :
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Phone :
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Relationship :
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First Name
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Middle Name
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Last Name
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| Name :
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DOB :
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| Nick Name :
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Legal Gender :
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Gender Identity :
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Address :
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City :
State :
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Zip :
Country :
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| Occupation :
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May we call at work?
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Work Hours :
Copay :
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| Secondary Insurance Information
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CarrierName :
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Other :
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Group # :
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Address :
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City :
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Policy # :
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State :
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Zip :
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Country :
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Phone :
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Relationship :
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1. How did you hear about us?
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2. What type of therapy are you seeking?
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3. What brings you in?
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4. What would your partner say?
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5. Length of these relationship:
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6. Can you tell me a little bit about yourself and your family/culture/upbringing?
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7. Can you tell me a little bit about what intimate relationships look like for
you?
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8. Do you have any dependents?
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9. Therapy before:
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10. Psychiatry before:
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11. Medications (type & dosage frequency):
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12. Alcohol and Drug Use (type & dosage frequency):
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| Describe use:
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13. Marijuana/Cannabis products:
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Do you have a medical marijuana card?
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| Describe use:
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14. Recreational drugs:
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| Describe use:
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15. Suicidality:
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| Ideation:
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| Describe, including whether ideation has occurred
in the last 2 weeks:
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| Planning:
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| Describe, including whether planning has occurred
in the last 2 weeks:
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| Attempts:
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| Describe including year(s) of occurrence and outcome:
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| Means:
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| 16. Self Harming Behaviours:
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| Describe, including most recent incident:
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| 17. Violence Towards Others:
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| Describe, including most recent incident:
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| 18. Physical/Emotional/Sexual abuse in the past:
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| Describe:
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| 19. Experience of life being threatened by person, accident, or natural disaster:
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| 20. Hospitalizations for Psychiatric Reasons:
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| Describe, including year of occurrence, diagnosis
(if possible) and resulting treatment:
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| 21. Actions taken concerning above risks:
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| 22. Religious Affiliation/Denomination:
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| 23. Occupation:
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| 24. Preferred Location:
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| 25. School: (grade/year, graduation date & current GPA):
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| 26. City Year Employee: (site name, site grade level, & program manager):
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| 27. Availability:
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| 28. Clinician assigned:
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| 29. Initial Appointment:
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| 30. Client Informed of Fee:
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| 31. Client Informed of 2 business day cancellation policy:
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| 32. Who did the intake:
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| 1. Occupation:
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| Youth worker:
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| No describe
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| Yes describe
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| 2. If City Year Employee: (site name, site grade level, & program manager):
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3. How did you hear about us?
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4. What type of therapy are you seeking?
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5. What brings you in?
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6. Client stated strengths
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7. Can you tell me a little bit about yourself and your family/culture/upbringing?
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8. Tell me a little bit about your community & social supports
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9. Do you have any dependents?
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10. Therapy before:
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11. Psychiatry before:
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12. Medications (type & dosage frequency):
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13. Alcohol and Drug Use (type & dosage frequency):
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| Describe use:
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14. Marijuana/Cannabis products:
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Do you have a medical marijuana card?
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| Describe use:
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15. Recreational drugs:
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| Describe use:
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16. Suicidality:
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| Ideation:
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| Describe, including whether ideation has occurred
in the last 2 weeks:
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| Planning:
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| Describe, including whether planning has occurred
in the last 2 weeks:
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| Attempts:
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| Describe including year(s) of occurrence and outcome:
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| Means:
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| Access to any weapons, if so type:
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| 17. Self Harming Behaviours:
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| Describe, including most recent incident:
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| 18. Violence Towards Others:
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| Describe, including most recent incident:
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| 19. Physical/Emotional/Sexual abuse in the past:
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| Describe:
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| 20. Experience of life being threatened by:
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| 21. Hospitalizations for Psychiatric Reasons:
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| Describe, including year of occurrence, diagnosis
(if possible) and resulting treatment:
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| 22. Actions taken concerning above risks:
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| 23. Religious Affiliation/Denomination:
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| 24. Preferred Location:
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| 25. School: (grade/year, graduation date & current GPA):
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| 26. Availability:
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| 27.Insurance and/or Sliding scale amount:
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| Everything below is for Office Staff Only to Complete
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| 28. Clinician assigned:
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| 29. Initial Appointment:
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| 30. Client Informed of Fee:
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| 31. Client Informed of 2 business day cancellation policy:
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| 32. Who did the intake:
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| 32. Youth worker:
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| 33. Describe if not occupation
(under occupation)
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