Date: _____________

2nd Star Counseling, LLC

Kathryn Raley, Psychotherapist
Secondary Education, B.S.
MA Community Counseling, Regis University
Certificate counseling, Youth and Adolescents
NCC

PO BOX 277
Lafayette, Colorado
80026
720-515-8796

Confidential Client Intake Form

Name: ______________________________________________________________________________________
Date of Birth: ____________

Age: ________

Gender: ___________________________________________

Marital/Relational Status: __________________

Partner/Spouse Name: ________________________________

Children (Names and ages):_____________________________________________________________________

Others living in your home ______________________________________________________________________
Occupation: ______________________________ Highest Level of Education: ____________________________

CONTACT INFORMATION
Address: ______________________________ Phone number(s): _____________________________________
___________________________________

At which number(s) may I leave a message?________________

EMERGENCY CONTACT
Name: ________________________________ Relationship to you: __________________________________
Address: ______________________________ Phone: _____________________________________________
______________________________________ Alternate phone:______________________________________

EXPECTATIONS FOR THERAPY

What brings you to seek therapy now and what do you hope to gain?

_________________________________

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Date: _____________
What are your concerns about therapy? __________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
If you have had an experience with therapy in the past, can you briefly describe what worked for you or what you
didnt work? _________________________________________________________________________________
___________________________________________________________________________________________
PAST YEAR CHECKLIST
Only respond to those areas that apply to you. Please rate the level of distress these issues have caused you in the
past year:
0
None

1
Minor

2
Moderate

3
Considerable

4
Extreme

____Sleeping Too Much/Too Little

____Drug/Alcohol (self or other)

____Financial Concerns

____Eating Too Much/Too Little

____Loneliness

____Legal Difficulties

____Mood Swings

____Caring for others

____Major Life Transition

____Angry Outbursts

____Distance from Loved Ones

____Gender Identity Conflict

____Depression

____Death/Major Loss

____Sexual Identity Conflict

____Repetitive Behaviors

____Past trauma

____Cultural Concerns

____Anxiety/Fear

____Health Problems

____Religious Conflicts

____Lack of Energy

____Sexual Problems

____Experienced Discrimination

____Hear/See things others cannot

____Relationship Problems

____Suicidal Thoughts/Actions

____Concerns regarding family

____Physical/Emotion/Sexual abuse

____Education/Work Concerns

MEDICAL AND MENTAL HEALTH TREATMENT INFORMATION

Please describe your physical and mental health including significant hospitalizations, illnesses, and/or
medications. ________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Are you currently receiving other mental health services or medical treatments?
___________________________________________________________________________________________
___________________________________________________________________________________________

Date: _____________
SUBSTANCE USE
Do you currently use tobacco, alcohol, or other drugs? _____________________________________________
Substance

How much and how often?

Past Use

_____________

_________________________________

______________________

_____________

_________________________________

______________________

_____________

_________________________________

______________________

_____________

_________________________________

______________________

(If applicable) When you used the most, how much did you use? ________________________________________
___________________________________________________________________________________________
Past substance abuse treatment? ________________________________________________________________

LEGAL HISTORY
Are you involved in the legal system or have you had significant legal issues in the past?
___________________________________________________________________________________________
___________________________________________________________________________________________
FAMILY INFORMATION
Please give me a brief family history. Describe family of origin and your current family dynamics:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

RELATIONSHIPS WITH OTHERS

Please describe the important people in your life and the quality of these relationships:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Date: _____________
Have you now or ever experienced violence, abuse, or threatening behavior in a
relationship?_________________________________________________________________________________
TRAUMA HISTORY
Please list any past traumatic experiences you have had (including but not limited to childhood abuse, military
combat, assault, natural disasters, life threatening illness).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
STRENGTHS AND RESOURCES
What helps you to make it through difficult times?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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Who can you count on for support in times of need? _________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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What gives you personal enjoyment?
___________________________________________________________________________________________
___________________________________________________________________________________________
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Tell me about special skills or abilities that you have.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Date: _____________
What communities are you a part of?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you have religious practices or spiritual beliefs that are important to you?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Is there anything else you think I should I know? _____________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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