Client Intake form (client information)

Client Intake Form

Poling Chan, MSW, LCSW
113 Coronado Court, Building 5, Unit A1 Fort Collins, CO 80525
Office: 970.481.7397
Fax: 970.237.3036

First Name:

Middle Name:

Last Name:

Gender:

Pronouns:

She/He/They

DOB:

Age:

Street, City & Zip:

Phone:

Email:

Employer / School:

Occupation:

Level of Education:

Name of school (if student):

Referred by:

Primary Care Physician:

Important medical history including recent or chronic conditions, surgeries and hospitalizations:

Ongoing physical symptoms that concern you:

Health providers involved in your care:

List any medication / supplements you are taking:

Previous treatment with mental health professionals:

If so, please list the issues you addressed

History of trauma / stressors:

Activities that replenish your energy or provide comfort?

Describe your history and relationship with alcohol/ substances ( as a user and/or witness):

Have you recently experienced a change/struggle in the following areas? Please explain:

Sleep:

Food Intake:

Exercise:

Use of screen time:

Work / study schedule:

Relationship with family / friends:

Who are involved in your support system? (include persons, animals, and communities):

Describe your reason/intention of seeking therapy now:

Do you have a question in mind?

Emergency Contact:

Phone / Email:

If client is a minor or dependent:

Please list parents/step-parents/gaurdians

Name:

DOB:

Phone:

Name:

DOB:

Phone:

If you are human, leave this field blank.