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Sarah E. Bollinger, PhD, LCSW
Home
Info
Contact
Intake Assessment
Name
*
First Name
Last Name
Date
MM
DD
YYYY
Email Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Age
Marital Status
Single
Married
Cohabiting
Divorced
Separated
Widowed
What sort of work are you doing now?
What is your annual household income?
Family members who live with you (Names, Relationship, Age, Gender)
Family of Origin - Parents
Married
Divorced
Separated
Family of Origin - Mother
Living
Deceased
How would you describe your relationship with your mother?
Family of Origin - Father
Living
Deceased
How would you describe your relationship with your father?
History of the following (for yourself - check all that may apply)
Alcohol/Drug Use
Domestic Violence
Mental Illness
Infidelity/Affairs
Verbal/Emotional Abuse
Sexual Abuse
Physical Abuse
Briefly Describe
History of the following in your immediate family?
Alcohol/Drug Use
Domestic Violence
Mental Illness
Infidelity/Affairs
Verbal/Emotional Abuse
Sexual Abuse
Physical Abuse
Briefly Describe
Have you worked with a counelor, psychologist, pastoral counselor, or therapist before?
yes
no
Counselor's Name
Please choose any of the following that you experience problems with.
Anger
Depression
Pornography
Loss/Grief
Lying
Job stress
Self-esteem
Worry
Relationships
Guilt/shame
Marriage problems
Suicidal thoughts
Mood swings
Obsessive thoughts
Self-injury
Communication
Sleeping problems
Crying Spells
Spiritual/Religious
Legal Problems
Disordered eating
Medical/Pain
Anxiety
Body Image
Sexual orientation
Gender identity
Sexuality
Breifly describe what brings you to therapy.
What are some goals that you have for therapy?
Emergency Contact - Name, phone, and email
Thank you!