Adult Intake Form

Client Name *:
Date Of Birth:
Address *:
Apt/Suite #:
City *:
State / Province *:
ZIP / Postal Code *:
Phone *:
Email *:
Gender:
Race:
Marital Status:
Primary Language:
Other Language:
Military Status:
Military Branch (if applicable):
Employment:
If other, please specify:
Highest Education Level:
Household Income:
Household Size *:
Have you or another member of your household received services from FSR before?:
Referral Source:
I am interested in the following services:

Emergency Contact #1
First Name *:
Last Name *:
Phone *:
Relation *:

Relative Contact #2
First Name:
Last Name:
Address:
City:
State / Province:
ZIP / Postal Code:
Phone:
Relation:

Information about Others (spouse, children, significant other) in household:
First Name:
Date Of Birth:

Health Information
Important present/past illness, allergies, infectious diseases (optional), injuries, or handicap
Name Of Doctor:
City:
List of medications you are currently taking:
Would you like us to coordinate care with above named providers?:
Nicotine Use?:
If yes how much?:

Family History
Were your parents separated or divorced?:
If yes, how old were you?:
If you were raised by anyone other than your own parents, briefly explain:
How many brothers do you have?:
List all their ages:
How many sisters do you have?:
List all their ages:
Mother:
Father:
Has anyone in your family had problems with mental illness?:
If yes, please explain:

Alcohol/Cllemical/Nicotine use History
Do you have a family history of alcohol/chemical abuse?:
Have you ever been concerned about your alcohol/chemical use?:
Have you ever used more chemicals than you intended to?:
Have you experienced legal problems or loss of job due to chemical use?:
Have you been confronted by someone on your use?:
What is your history of Nicotine use?:

Alcohol/Chemical History
Have you ever had physical discomfort from chemical use (e.g., shakes, hallucinations, or blackouts)?:
Have you tried to control and/or stop your using?:
Have you ever received treatment for chemical abuse or dependency? :
When & Where?:

Please answer the following questions
Do you have concerns about your ability to parent?:
Have you ever been concerned about your temper?:
Have you ever been depressed? :
Have you ever had psychotherapy or counseling? :
Do you have concerns about your sexuality? :
Have you ever been physically abused? :
Have you ever been sexually assaulted?:
Have you ever been abused by your partner?:
Have you ever abused your partner? :
Have you ever attempted suicide?:
Have you ever had/have legal concerns?:
Have you been hospitalized for emotional/mental illness?:
Do you have concerns about gambling? :
Do you have concerns about eating?:
Do you have concerns about self-harm?:
Have you ever experienced a traumatic event?:

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