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Mary Quirk, M.A., L.P.C., N.C.C.
45 County Road 537 West • Colts Neck, N.J. 07722 (732) 303-7999
CLIENT INTAKE FORM
Date _________________ Name __________________________________________________Address _______________________________________________________________________City _______________________________ State __________ Zip Code ___________________Home Phone _________________ Work Phone _______________ Cell Phone _____________Age ___________ Date Of Birth _______________ Social Security # _____________________Emergency Contact Name ______________________ Emergency Contact’s # ______________Education/Last Grade Completed _____________________ Optional: Religion _____________Are You Employed? ______ Where? __________________________________________ FT/PTMarital Status ______ # of years you have been together? __________________________________Partnter’s Name_________________________ Partner’s Employer ______________________________Is this your first marriage? ________________________ Your spouse’s? ___________________________Children: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ DYFS History (previous or present involvement) __________________________________________________________________________________________________________________________________________________________________________________________________Do you have any involvement with the legal system? ____________________________________Does your partner have a criminal record? _______________________________________________(if you answered yes please explain) ________________________________________________________Does your partner use drugs or alcohol? ______________________________________________(if you answered yes please explain) ________________________________________________________Does your partner have a history of mental illness? ____________________________________________(if you answered yes please explain) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please fill out if you or a family member have been in counseling or therapy before: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you or a family member ever been hospitalized for psychiatric reasons? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you ever had a serious injury or illness? ________Yes __________No __________If yes, please explain __________________________________________________________________Do you have any other medical problems? __________Yes __________No __________If yes, please explain __________________________________________________________________Please list any medications you are taking: ___________________________________________________________________________________________________________________________________ Do you or have you ever used alcohol while taking this or any other medication? ____Yes _______NoDo you ever see a new doctor because your regular doctor would not refill your prescription? Y/NHas anyone in your family/friends expressed concern over your drinking or use of drugs? Y/NDo you use alcohol at all? _______Yes ________No What do you like to drink? ____________________________________________________________Do you ever get drunk? _______Yes___________________No_______________________________Do you ever drink alone? _______Yes___________________No_______________________________Do you have trouble remembering things when you drink? _______ Yes ___________ No ______________Do you think that alcohol or drugs are a problem for you? _______ Yes __________ No _______________If yes, please explain: ____________________________________________________________________Do you have any other addictions (Gambling, Food, Etc.)? _____ Yes _________ No_______________If yes, please explain: ____________________________________________________________________ Are you currently in a recovery program? Yes __________ No_______________If yes, which one? _____________________________________________________________________ PLEASE CIRCLE ALL AREAS OF CONCERN TO YOU:
1. PHYSICAL ABUSE2. EMOTIONAL ABUSE3. SEXUALITY4. SEXUAL ASSAULT5. DEPRESSION6. ANXIETY7. RELATIONSHIPS8. SELF-ESTEEM9. PARENTING10. BEHAVIOR OF CHILDREN11. SEPARATION / DIVORCE12. FINANCES13. LEGAL ISSUES14. GAMBLING15. ANGER MANAGEMENT16. SELF-ABUSE17. PHYSICAL ABUSE OF CHILDREN18. EMOTIONAL ABUSE OF CHILDREN19. SUICIDAL THOUGHTS20. HOMICIDAL THOUGHTS21. HEALTH CONCERNS22. FEAR OF MENTAL INSTABILITY24. ALCOHOL USE BY ___ME____PARTNER______CHILD________PARENT25. DRUG USE BY ______ME_____PARTNER_______CHILD_______PARENT26. EATING DISORDER______ANOREXIA________BULEMIA______OVEREATING In the space below briefly describe what brings you to counseling at this time.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please read over the list of drugs on the next four pages and place a check next
to any you have used in the past or are presently using.
ANTI-ANXIETY
ATIVANBUSPARKLONOPINLIBRIUMVALIUMXANAXOTHER ANTI-DEPRESSANTS
CELEXADESPIRAMINEELAVILEFFEXORGEODONLITHIUM/ ESKALITHLUVOXPAMELARPAXILPROZACSERZONETOFRANILWELLBUTRINZOLOFTLEXAPROOTHER ANTI-PSYCHOTICS
CLOZARILRISPERDALZYPREXASEROQUELTHORAZINEOTHER MOOD STABILIZERS
DEPAKOTELITHIUMNEURONTINREMERONTEGRETOLTOPIMAXOTHER SLEEPING PILLS
AMBIENHALCIONPLACIDYLRESTORILTRAZODONEOTHER PAIN KILLERS
CODEINEDARVONDEMEROLDILAUDIDFIORNALMORPHINEPERCODAN/ PERCOCETOXYCODONEVICODAN OTHER DRUGS
BARBITUATESCOCAINE/CRACKCRYSTAL METHGHBPCP/ ECSTACY/ SPECIAL KHEROINMETHADONEROPHYPHOL/ ROOFIESSPEEDSTEROIDSTOBACCOOVER THE COUNTEROTHER FAMILY MENTAL HEALTH HISTORY:In the section below identify if there is a family history of any of the following. If yes,please indicate the family member’s relationship to you in the space provided (father,grandmother, uncle, etc.).
Please Circle & List Family Member
Alcohol/Substance Abuse yes/no
Anxiety yes/no
Depression yes/no
Domestic Violence yes/no
Eating Disorders yes/no
Obesity yes/no
Obsessive Compulsive Behavior yes/no
Schizophrenia yes/no
Suicide Attempts yes/no
ADDITIONAL INFORMATION:1. Are you currently employed? If yes, what is your current employment situation: _______________________________________________________________________ Do you enjoy your work? Is there anything stressful about your current work?____________________________________________________________________________________________________________________________________________ 2. Do you consider yourself to be spiritual or religious? _____________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. What do you consider to be some of your strengths?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. What do you consider to be some of your weakness?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. What would you like to accomplish out of your time in therapy?__________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://www.maryquirk.com/userfiles/147447/file/Intake%20Form_Layout%201.pdf