Individual Intake Form - Jackson Hole Family Solutions

PERSONAL INFORMATION

Name*

First Last

Name of Therapist

Lindley Kunce, PC
Laura Santomauro, LMFT

Address*

PO Box City State / Province / Region ZIP / Postal Code Country

Date of birth – month, day, year*

Phone*

Email address*

May we contact you via text?*

Yes
No
I prefer email
I prefer phone call

Relationship Status*

Single
Engaged
Married
Divorced
Partners

How long have you been in relationship/married?

Number of children

List children names and ages

PRESENTING PROBLEM

Who referred you to JHFS?*

Reason for referral.*

Briefly describe presenting problem (why you have made an appointment)*

How long has problem occured?*

Briefly outline your goals for therapy*

Briefly describe previous treatment for this issue. Who did you see before and for how long?*

Please list any medications you are currently taking and for what purpose as it relates to these issues

Who is the prescribing doctor?

PERSONAL HISTORY

I have received individual counseling in the past.*

Yes
No

If YES, please list provider and reason for being in individual counseling.

Do you have personal history of suicide attempt/ideation?*

Yes
No

If YES, please list dates and briefly describe history

Do you have personal history of mental health hospitalization?*

Yes
No

If YES, please list dates and briefly describe history

Please list personal strengths:*

PERSONAL HISTORY – substance abuse/addictions

Do you have a personal history with addictions?*

drugs/alcohol
sex or porn
food
OTHER
NONE

Have you received previous treatment for this issue?

Yes
No

If YES, please list dates, facility and outcomes.

Are you currently using substances?*

Yes
No

Please list all substance you are currently using and frequency of use (i.e. multiple times/day, daily, weekly, monthly)

Date of last use

PERSONAL HISTORY – sexual trauma

Do you have personal history of sexual trauma?*

Yes
No

If YES, please list dates/ages and briefly describe history… . to the best of your ability

Have you received previous counseling for this issue?

Yes
No

If YES, please list dates, providers and outcomes

PERSONAL HISTORY – family violence

Do you have personal history of family violence – verbal abuse or physical abuse?*

Yes
No

If YES, please list dates/ages and briefly describe history…. to the best of your ability

Have you received previous counseling for this issue?

Yes
No

If YES, please list dates, providers and outcomes

RELATIONSHIP HISTORY

I am currently in a committed relationship.*

Yes
No

Is there relational history of domestic violence?*

Yes
No

Who engages in violent behaviors

Partner
Self
Both

Is domestic violence ongoing?

Yes
No

Has there been treatment for issue?

Yes
No

If yes, please indicate if, when, where you received couples counseling for this issue

Partner history of substance abuse?*

Yes
No

Is partner currently abusing substances?*

Yes
No

PAYMENT AGREEMENT

I have read, understand & authorize the following payment policies (checking the boxes below indicates approval response ("yes"):*

Credit card will be held on file and charged accordingly on dates of service
Late cancellations (less than 24 hours) will yield a full fee payment for hour
I will be charged full payment for “no show” sessions
I authorize payments for services, late cancellations and no show fees accordingly

Credit Card Information*

Please include: 1. credit card number 2. expiration date 3. CVV 4. Zip Code

Additional info you feel is important for your therapist to know

Additional questions you have regarding the counseling process

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