Julianna Waters, MSW, LCSW
833 SW 11th Ave, Suite 428, Portland, OR 97205
503-225-0908 • [email protected]
Office Use Only
Date Opened
Date Closed
Client Intake Evaluation
(Please use black ink.)
_____________________________________________________________________________________________________________
Name
_____________________________________________________________________________________________________________
Partner’s Name (if being seen as a couple)
_____________________________________________________________________________________________________________
Address
City
State
Zip
Telephone Numbers: ___________________________ ___________________________ ___________________________________
Home
Work
Cell / Other
May I leave a message for you at: Home?
Work?
Yes
Gender:
M
F
__________
Age
No
Yes
__________________________
Birth Date
No
_________________________________________
E-mail Address
_______________________________________________
Relationship Status
__________________________________
SSN
Household Members
Name
Age
Relationship
Emergency Contact
_____________________________________________________
Name
_____________________________________________________
Phone Number
_____________________________________________________
Occupation
_____________________________________________________
Relationship
Current Information
Employer
Employment History (briefly describe past and present work, years at job):
Primary Care Physician
_____________________________________________________________________________________________________________
Name
_____________________________________________________________________________________________________________
Address
City
State
Zip
_________________________________________________
Phone Number
Medical History (surgeries, serious illnesses, chronic issues):
Do you use alcohol?
Yes
No
________________________________________
If so, how much?
Do you use recreational drugs?
Yes
No
_____________________________________
How often?
_______________________________________________________________________
If so, what type(s)?
__________________________________________
If so, how much?
______________________________________
How often?
Life Information
Have you sought counseling before?
Who referred you to me? _______________________________________
Yes
No
If yes, from whom? When? For what issue(s)?
Why are you seeking help now?
Tell me about the things you love the most:
Tell me about experiences that have been most challenging for you:
Have you had experiences that you would describe as traumatic? If so, and you are willing, please tell me briefly of them:
If you have brothers or sisters, please list them in birth order (eldest to youngest):
Age
Name
Are your parents still living?
Yes
No
Where do they live now
If not, when and
how did they die?______________________________________________________
If living, are they married, divorced or separated?
If divorced/separated, when?_______________________
M
Where do they live now?
Where did you grow up?
Is there anything else you would like me to know?
D
S
Please check any of the following experiences that you are having:
Depression
Feeling stressed
Feeling Hopeless
Self esteem issues
Extreme Sadness
Easily irritated
Feeling tearful
Perfectionism
Trouble Concentrating
Feeling guilty
Change in sleeping habits
Obsessions or Compulsions
Memory Problems
Feeling nervous
Lack of energy
Feeling fearful
Change in eating habits
Sudden feelings of panic
Weight changes
Physical complaints of pain
Feelings of extreme happiness
Muscle tension
Changes in sexual interest or function
Problems with anger
Trouble performing your job
Acting violently
Problems with family or friends
Thoughts of hurting yourself or others
Lack of enjoyment in usual activities
Thoughts of killing yourself or others