Client Intake Form

Let's get this growth process started!

Please fill in the form below before your first appointment.

Personal Info

Physical History

Are you now under a doctor's care?
Are you taking any medication?
Have you ever been hospitalized for a physical illness?
Do you smoke?
Do you take drugs?
Do you take drink?
Any Previous Therapy/Counseling?

Work History

Family Systems Information

Father Alive?
Mother Alive?
Living with a partner

Children

Child 1 - sex
Child 2 - sex
Child 3 - sex
Child 4 - sex
Child 5 - sex
Child 6 - sex

Siblings

Sibling 1 - sex
Sibling 2 - sex
Sibling 3 - sex
Sibling 4 - sex
Sibling 5 - sex
Sibling 6 - sex
Family Alcoholism or Domestic Violence?
Sexual Addictions or Abuse
Parents divorced?
Any step-parents?

Spiritual History

Is this an important part of your life?

Emotional Status

Are you currently experiencing strong emotions?
Do you make decisions based on your emotions?
Did you have what you would consider to be childhood or other traumas?
Have you been treated for emotional disturbances?
Have you had any thoughts of suicide
Do you have any thoughts now

Present Situation

Personal Agreements

I understand that I may be asked to do certain “homework exercises” such as reading, praying, changing behaviors, and otherwise acting in my own best interest. I understand that I am entirely responsible for my own actions and I will always make my own final decisions regarding counseling.

I further understand that much of the work done will be to resolve issues and will depend on my honesty, and willingness to do the things I need to do to move forward even if it is painful and difficult.

I understand that whatever I say in a session is strictly confidential and will not be released to anyone without my consent unless I am violating codes of abuse, harm to myself or others.

I understand that I will pay in full for appointments not canceled with 24 hours’ notice.

As your therapist/counselor, you honor me by sharing your life and growth with me. I will not hide myself behind silence or position and will have high regard for you as a person. I will bring the best that I know from my study and experience. I will bring you the highest of my insight, wisdom, and spiritual guidance. I will keep a holistic perspective in our work together because I believe that the Physical, Spiritual, and Soul (mind, will, emotions) all work together to form the wholly healthy person.

You can expect truth from me even when you may not want to hear it. I will always have compassion and empathy for you in all that we do. I value you as a person in need of care. I will do my best to honor that.

Dr. John E. N. Daniel

I have read and agree to the above terms