Jenevieve S. Glemming, MA, LPC, CD(DONA)
Nurturing Strategies, LL C
Licensed Professional Counselor (CO#5384)  National Provider ID: 1336447630
1503 Yarmouth Avenue  Boulder, Colorado 80304
[email protected]  Phone: 720.239.2347
** CONFIDENTIAL Client Intake Form**
Please email this form fully completed to [email protected] 24hrs prior to your first appointment.
(NOTE: by sending electronically, you understand that electronic communications are not always confidential)
Today’s Date date
Name: Prefer to Be Called Click here to enter text.
Last Name last name
First Name first name
Date of Birth date of birth
MI middle
Age age
Contact Information:
Street street City/State city, state Zip code zip
Who lives there with you (& their relationships to you)? text
Email Address your email address
Home#: home # Work#: work # Cell #: cell #
Which number(s) may I call & leave a message on?
Emergency Contacts:
text
(ONLY used in an emergency & I always attempt to contact you first)
Name name Phone # number Relationship relationship
Name name Phone # number Relationship relationship
Name name Phone # number Relationship relationship
Demographics
(Optional) Ethnic Group You Identify In: ethnic group
(Optional) Religious/Spiritual Affiliation(s) religion/spiritual
(Optional) Relationship Status single, partnered, married, separated, divorced, widowed, other
(Optional) Do you have children? ? yes or no
If yes, how many, ages, where do they live? text
(Optional) Gender You Identify As: gender
Preferred Gender Pronoun: (Optional) pronoun.
(Optional) Sexual Orientation: orientation
(Optional) Current Employment/Student Status: employed (FT/PT); not in labor force; student (FT/PT)
SYMPTOM CONCERNS:
Please indicate which symptoms you are concerned about:
Sleep:
Appetite:
No Problem; Too much; Not Enough; Hard time falling asleep; Hard
time staying asleep; Hard time waking up; Nightmares; Not feeling
rested; I don’t know; etc
No Problem; Increased; Decreased; I don’t know; etc
None; Infrequent; Often; (frequency per month/week/day)
Energy:
Normal; Increased; Low; Up and Down; I don’t know; etc
Interest in sex:
Normal; Increased; Low; Difficult; I don’t know; etc
Concentration:
Normal; Difficult; Poor; Increased; I don’t know; etc.
Memory:
Normal; Good; Some Difficulty; Poor; I don’t know; etc
Depressed or sad:
All the time; Most Days; Some Days; Not at all
Anxiety:
All the time; Most Days; Some Days; Not at all
Anger / Irritation:
All the time; Most Days; Some Days; Not at all
Thoughts:
worries; fears; repetitive; detached; paranoid; sluggish; I don’t
know; etc.
Suicidal thoughts:
All the time; Most Days; Some Days; Not at all
Mood (Generally):
Click to enter text.
Pain Tolerance:
Unusually high; Unusually low; I don’t know; etc.
Reaction to Touch, Sounds, Lights, Tastes, Smells Click to enter text.
Social (friends, support):
Click to enter text.
Exercise:
PERSONAL BACKGROUND
(fill out as little or as much as you feel comfortable)
Birth & Family History (if known):
Describe anything you know of about your birth and/or your birth parents’ experiences around
the time before, during or after your birth. Click here to enter text.
Briefly, describe your family of origin: Click here to enter text.
What was it like growing up in your family? Click here to enter text.
List any mood disorders, psychiatric or medical illnesses (treated or untreated) that your family /
relatives experience(d): Click here to enter text.
Developmental History:
Any delays or accelerations in your development (e.g., motor, cognitive, verbal, emotional, social)?
Click here to enter text.
Any school-related concerns growing up (learning disabilities, problems with peers)?
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Medical History:
Please describe current medical problems/concerns: Click to enter text.
Please describe what you have tried, what has not helped or what makes it worse:
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Please describe what helps (even moderately) or what makes slight improvements/tolerable, etc:
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Please list all medications you currently use (both prescribed and non-prescribed):
Medication/Herb/Supplement – Dosage – Used to Treat – Prescribed by
Medication/Herb/Supplement – Dosage – Used to Treat – Prescribed by
Medication/Herb/Supplement – Dosage – Used to Treat – Prescribed by
Medication/Herb/Supplement – Dosage – Used to Treat – Prescribed by
Please list any current/previous medical services, including hospitalizations
Doctor/Procedure – Dates – Reason for Treatment – Outcome
Doctor/Procedure – Dates – Reason for Treatment – Outcome
Doctor/Procedure – Dates – Reason for Treatment – Outcome
Doctor/Procedure – Dates – Reason for Treatment – Outcome
Anything relevant from your medical history/past that you’d like me to know about?
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Mental Health History:
Have you been in counseling before? yes or no If yes, what were your experience(s) like: Click here
Past trauma, abuse, losses, difficult life transitions and/or substance use/abuse?
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Please describe your current alcohol use and frequency: Click to enter text.
Please describe your current drug/substance use and frequency: Click to enter text.
Have you ever experienced abuse?
Physical
yes or no
Sexual
yes or no
Emotional
yes or no
Other
yes or no
details or additional info here that you wish to share …
Have you ever been hospitalized or attempted suicide?
yes or no
Have you ever been charged with a crime, arrested or convicted? yes or no
Do you have any work-related problems or difficulties in school?
yes or no
Anything else that you’d like me to know about? Click here to enter text.
PRIMARY CONCERN(S)
(fill out as little or as much as you feel comfortable)
What are some of the reasons you are seeking support? Click to enter text.
What have you tried already to change/manage the problem/concern? Click to enter text.
Why are you seeking support at this time/now? Click to enter text.
What are your goal(s) for psychotherapy / describe what you would like to change / how will
you know you have reached your goals/completed psychotherapy? Click to enter text.
How do you imagine psychotherapy will help you make these changes? How long do you think
the process might take? Click to enter text.
What are your strengths / things you enjoy (talents, hobbies, education, personality, habits, passions,
relationships, skills, etc)?
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Anything else you’d like me to know about related to your primary concerns? Click here to
enter text.
Referred by: Click here to enter text.
Occasionally, I send thank-yours to referrals in a general manner (not revealing who is seeing me).
Would that be okay with you? yes or no, not applicable
ANYTHING ELSE:
What concerns / questions do you have? Click here to enter text.
Anything else you’d like me to know in working together: Click here to enter text.