Young Adult/Single Intake Form This is a confidential questionnaire that will provide me with information that will be helpful in coaching or therapy. If there are questions that you would rather not answer, leave them blank. You will receive an email copy of your form upon completion that you can print out for yourself.Name* First Last Birth Date* MM slash DD slash YYYY Home PhoneCell PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Parents Name Emergency Contact Emergency Contact PhoneToday's Date* MM slash DD slash YYYY What made you seek therapy/coaching at this time?If therapy/coaching is successful, how will you and/or your life be different? What are your therapy/coaching goals?Name, ages and brief description of people living in your home:Education (grade and school you attend OR last school you attended, did you graduate, GED?):Job History (name of employer, dates, reason you no longer work there):Health History: include current healthHealth History: Current health issuesCurrent medicationsHealth History: Do you have a problem with: alcohol drugs food cravings weight gain/loss body image insomnia PMS/moods depression anxiety/PTSD anger shame/shyness social anxiety focus motivation Family of Origin: Names, ages, brief descriptions:You can draw the family tree on a sheet of paper and bring with you to the next session if you prefer.What kind of relationship do you have with your mother?What kind of relationship do you have with your father?What kind of relationship do you have with your siblings?What kind of relationship do you have with other family members (grandparents, cousins, etc)?Important events in childhood:Important events in teenage years:Trauma History:Have you ever been sexually or physically abused? By who, when, how long, etc?What significant losses have you experienced?Have you ever made a suicide attempt? Please give details:Describe yourself, including positive and negative traits:What do you like about yourself? What are your strengths?What happens when you fight?Check all of the statements that reflect what you DO and the way you FEEL when you are fighting with someone. I attack I avoid conflict I blame I clam up I criticize I defend I get louder I get quiet I give up I give in I pursue I withdraw I seek closeness I seek distance I cling I push away I try to engage my partner I try to manage the conflict I make demands I am reasonable I take control I shut down I become passive/aggressive I stonewall Check any of the below you may feel: abandoned afraid/anxious alone angry attacked blamed controlled confused criticized disconnected flooded with emotion guarded hopeless hurt like I don't know what I've done that I don't matter ignored inadequate intimidated isolated like it's always my fault judged misunderstood numb overwhelmed put down'rejected scared shut out/pushed away unable to calm myself down unable to focus my thoughts unappreciated unattractive unimportant un-loveable other When you fight do you tend to: Fight/get assertive, Flight/try to get away, Freeze/give inWhen you fight your parents tend to: Fight/get assertive, Flight/try to get away, Freeze/give inExplain any previous therapy you have been in. What has been helpful? What has not been helpful?Is there anything else you want me to know?PhoneThis field is for validation purposes and should be left unchanged.
