Confidential Client Intake Form Please enable JavaScript in your browser to complete this form.Name *FirstLastAge *Date of Birth *Gender *MaleFemaleEmail *Phone Number *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneWork PhoneCell PhoneEmployer/Company Name: *Check box if ok to reach you at:HomeWorkOK to leave Voicemail at home?OK to leave Voicemail at Work?Marital Status: *MarriedDivorcedSeparatedNever MarriedDate of Marriage | Divorce | Separation:Spouse's Name:Spouse's Phone (Best number):Spouse Date of Birth:Spouse's Employer/Company Name:Children (Names and Ages):Other information that may be helpful that you would like to share:Desired solution or goals for therapy: *Previous Counseling: *YesNoIf Yes, with whom?Date of last session:How long did you work with this counselor?Name of your personal physician: *Date of last visit: *Do you have any of the following health issues:AllergiesSleep difficultiesDifficulty concentratingMemory lossRacing heart beatOtherPlease explain/elaborate on health issues:Current medical problems / treatments:Please list all medications you are currently using (prescribed or otherwise):Adult Checklist of Concers *I have no problem or concern bringing me hereAbuse – physical, sexual, emotional, neglect: (of children or elderly persons), cruelty to animalsAgression, violenceAlcohol useAnger, hostility, arguing, irritabilityAnxiety, nervousnessAttention, concentration, distractibilityCareer concerns, goals, and choicesChildhood issues (your own childhood)CodependenceConfusionCompulsionsCustody of childrenDecision making, indecision, mixed feelings, putting off decisionsDelusions (false ideas)DependenceDepression, low mood, sadness, cryingDivorce, separationDrug use – prescription medications, over-the-counter medications, street drugsEating problems – overeating, undereating, appetite, vomiting (see also “Weight and diet issues”)EmptinessFailureFatigue, tiredness, low energyFears, phobiasFinancial or money troubles, debt, impulsive spending, low incomeFriendshipsGamblingGrieving, mourning, deaths, losses, divorceGuiltHeadaches, other kinds of painsHealth, iliness, medical concerns, physical problemsHousework/chores – quality, schedules, sharing dutiesInferiority feelingsInterpersonal conflictsImpulsiveness, loss of control, outburstsIrresponsibilityJudgment problems, risk takingLegal matters, charges, suitsLonelinessMarital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointmentsMemory problemsMenstrual problems, PMS, menopauseMood swingsMotivation, lazinessNervousness, tensionObsessions, compulsions (thoughts or actions that repeat themselves)Oversensitivity to rejectionPanic or anxiety attacksParenting, child management, single parenthoodPerfectionismPessimismProcrastination, work inhibitions, lazinessRelationship problems {with friends, with relatives, or at work)School problems (see also “Career concerns…”)Self-centerednessSelf-esteemSelf-neglect, poor self-careSexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”)Shyness, oversensitivity to criticismSleep problems – too much, too little, insomnia, nightmaresSmoking and tobacco useSpiritual, religious, moral, ethical issuesStress, relaxation, stress management, stress disorders, tensionSuspiciousnessSuicidal thoughtsTemper problems, self-control, low frustration toleranceThought disorganization and confusionThreats, violenceWeight and diet issuesWithdrawal, isolatingWork problems, employment, workaholism/overworking, can’t keep a job, dissatisfaction, ambitionAny other concerns or issuesPlease look back over the concerns you have checked off and choose the one that you most want help with. It is: *How did you hear about Restoration Counseling NW: *May I thank them for the referral:YesNoToday's Date:Signature Clear Signature Please use your mouse (or finger if touch screen enabled) to sign your name.Submit Restoration Counseling NW717 NE 61st Street, Suite 201, Vancouver, WA 98686