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Home
About Us
Services
Counseling
Forms
How was your service
Become a Client
Contact
Payment/ Rates
THERAPY/COUNSELING SERVICES
INTAKE INFORMATION
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Today's Date
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MM/DD/YYYY
Name
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First
Last
Phone Number
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Date of Birth
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MM/DD/YYYY
Guardians Name (if under 18 years old)
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First
Last
Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Emergency Contact
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First
Last
Emergency Contact Number
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Marital Status
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Single
Married
if married, number or years
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Please check the areas that are concerns for you
Choose Any
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Family / Children
Marital Relationship
Other Relationships
Employment
Finances
Living Situation
School
Legal Problems
Other (specify)
Comment
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Symptom / Problem List
Check any item that has been a concern or problem and indicate how long.
Physical
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Sleep Problems
Fatigue / Loss of Energy
Appetite Change / Weight Loss or Gain
Headaches
Nausea, Diarrhea, or other Abdominal Distress
Dizziness or Faintness
Shortness of Breath
Trembling or Shaking
Trouble Swallowing / “lump in throat”
Palpitations / Accelerated Heart Rate
Nightmares / Frightening Dreams
Sweating
Premenstrual Syndrome (PMS)
Mood
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Depressed Mood
Loneliness
Frequent Crying
Mood Swings
Feeling of Helplessness and Hopelessness
Lack of Interest in most Activities
Low Self-Esteem
Thoughts about Suicide
Suicide Plans
Suicide Attempts
Irritability
Anxiety
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Excessive Worry
Anxiety, Nervousness
Panic Attack
Fears (including phobias)
Social Fears, Shyness
Guilt Feelings
Behavior
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Withdrawal, Isolation
Lack of Assertiveness
Perfectionism
Hyperactivity
Irritability
Agressive Behavior
Self-Harming Behavior
Thoughts, Perceptions
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Problem with Memory
Difficulty Concentrating
Disorientation / Confusion
Excessive Fantasy / Daydreaming
Preoccupation
Racing Thoughts
Hallucinations
Medical
Primary Health Insurance Provider
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Group #
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Policy #
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Thank you AR Counseling looks forward to serving you!
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