CLIENT INTAKE FORM B3 Counsel-B3 Counsel LLC

First name

Last name

Email

Phone number

Cell/other

Work phone

Current address

Birth date

Age

Gender

Male

Female

Marital status

Number of children:

Children ages

Who may we contact in case of an emergency

Contact telephone number

Referred by:

Internet search

Word of mouth

Other

Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services?

Yes

No

Reason For Change

Are you currently taking any psychiatric prescription medication?

Yes

No

If yes, please list:

Have you been prescribed psychiatric prescription medication in the past?

Yes

No

If yes, please list:

Have you been psychiatrically hospitalized in the past?

Yes

No

If yes, please list dates and locations

Please provide the name, address and telephone number for your primary care physician:

How is your physical health at the present time?

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, thyroid dysfunction, etc.):

Are you on any medication for physical/medical issues?

Yes

No

If yes, please list:

Are you having any problems with your sleep habits?

Yes

No

If yes check those that apply:

Have you experienced a weight change in the last two months?

Yes

No

If yes, how many days per week do you exercise? How many minutes/hours per session?

Do you consume alcohol regularly?

Yes

No

In one month, how many times do you have four or more drinks in a 24-hour period?

How often do you engage in recreational drug use?

What kinds of recreational drugs do you use:

Are you currently in a romantic relationship?

Yes

No

If yes, how long have you been in this relationship:

On a scale from 1-10 (10 being great), how would you rate the quality of your relationship?

In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?

Check the issues below that apply to you. Choose 1 or more

Have you felt depressed recently?

Yes

No

If yes – For how long

Have you had any suicidal thoughts recently?

Yes

No

If yes, how often?

Frequently

Sometimes

Rarely

Have you ever had suicidal thoughts in your past?

Yes

No

IF yes, how long ago

How often did you have these thoughts?

Frequently

Sometimes

Rarely

The following is to provide information about your family history. Please check. If yes, please indicate the family member affected.

Please indicate the family member affected from each options above.

Do you practice a specific religion?

Yes

No

If yes, what is your faith?

Are you currently employed?

Yes

No

What is your position at work?

Are you happy in your current position?

Yes

No

Does your work make you stressed?

Yes

No

If yes, what are your work-related Stressors?

List your strengths and what you like most about yourself:

List areas you feel you need to develop

What are some ways you cope with life obstacles and stress?

What are your goals for therapy/what would you like to accomplish?

By signing below, I am acknowledging that I have chosen to receive therapy services in the form of evaluation and psychotherapy from B3 Counsel, Michael Bullard, LCT. My decision is voluntary, and I understand that I may terminate these services at any time. I also understand that during the course of treatment I may need to discuss material of an upsetting nature in order to resolve my problems. Further, I understand it cannot be guaranteed that I will feel better after completion of treatment.

Your Signature

DISCLOSURE:

All payments are to be made on the B3 website via debit or credit card(s) or Paypal and are to be paid in advance of the session.

B3 does not accept any form of insurance and cannot process any type of payment other than that mentioned above.

The hourly rate is stated on the website as $135.00 per hour.

When possible, sessions are conducted via ZOOM. This offers our clients the comfort zone of their home. Other arrangements can be made when necessary, at B3’s discretion.

CLIENT INTAKE FORM B3 Counsel

General Health Information

Family Mental Health History

Religious/Spiritual Information

Occupational Information

Other Information