PeopleHouse

Name

First

Last

Age

Date of Birth

I identify my gender as

My pronouns are

Ethnicity

Asian or Pacific Islander

Black or African American

Hispanic or Latino/a/x

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

A race or ethnicity not listed here

Why are you seeking counseling?

Please list any other reasons you are seeking counseling here, and/or include any preferences, hopes, fears, reservations, or special needs you may have regarding counseling:

What is your ability to pay, per session?

Are you employed?

Full time

Part time

Unemployed

Type of counseling:

Individual

Couple

Family

Preference of People House location:

Denver

Aurora

Virtual

Contact Information

Street Address

City

Zip Code

County

Email

Is it okay to email you?

Yes

No

Cell Phone Number

Is it okay to leave a voicemail?

Yes

No

Is it okay to text?

Yes

No

Home phone number

Is it okay to leave a voicemail?

Yes

No

Work phone number

Is it okay to leave a voicemail?

Yes

No

Emergency Contact Information

Emergency Contact Name

Emergency Contact's Phone Number

Alternate Emergency Contact Name

Alternate Emergency Contact Phone Number

Career/Education Information

Occupation

Place of work

Family Information

Relationship Status

If in relationship please list partner/spouse name(s)

Do you have children?

Yes

No

If yes, please list their names

Do they live with you

Full time

Part time

No

N/A

Health Information

Are you on any medication?

Yes

No

If yes, please list medications/dosage

Frequency taken

What is the general condition of your health?

Physician name

Physician phone number

Please describe your physical and mental health including significant hospitalizations, illnesses

Are you currently receiving other mental health services or medical treatment?

Yes

No

Safety Assessment

Have you ever given serious consideration to, or attempted to, end your own life?

Yes

No

If yes, date of last occurrence - please describe:

If yes, do you currently feel this way? Do you have a plan?

Have you ever given serious consideration to, or attempted to harm another person:

Yes

No

If yes, last occurrence:

If yes, do you currently feel this way? Do you have a plan?

History

Do you currently use tobacco, alcohol, or other drugs?

Yes

No

Please list substances used currently or in the past? How much and how often?

Past substance abuse treatment?

Yes

No

Are you involved in the legal system or have you had significant legal issues in the past?

Yes

No

If yes, please describe:

Please give me a brief family history. Describe family of origin and your current family dynamics:

Expectations for Therapy

What brings you to seek therapy now and what do you hope to gain?

Is there anything I have not asked you that is important for me to know?

What are your concerns about therapy?

Have you been in counseling before?

Yes

No

If yes, was your past experience positive or negative? Please explain:

Client Portal for Jane Doe

Affordable Counseling Program Intern

Intake Forms

Therapeutic Client Intake Questionnaire TEMPLATE

Contact Information

Emergency Contact Information

Career/Education Information

Family Information

Health Information

Safety Assessment

History

Expectations for Therapy

Surveys

Disclosure

Downloadable Forms