Counseling in Chicago with Bill Martin, LCSW http://www.counselinginchicago.com Exploring counseling & psychotherapy, what works, and the research that supports it. Bill Martin, LCSW 312-409-0632 Bmartin222@aol.com Wed, 07 Jan 2009 23:42:52 +0000 http://wordpress.org/?v=2.0.5 en Intake form (Best to use Mozilla Firefox Browser) http://www.counselinginchicago.com/intake-form/ http://www.counselinginchicago.com/intake-form/#comments Tue, 13 May 2008 00:12:49 +0000 Bill Martin, LCSW Counseling & Psychotherapy http://www.counselinginchicago.com/intake-form/ Intake form

Complete these questions prior to our first session if possible. If this is for couples therapy, each person should complete this form.

Please note that you it is best to access this form via the Mozilla Firefox browser (click here for free download) and then can copy and paste this form into a Word document. Use as much space as you need.

Name:

Address:

Phone: home cell work

Birthdate:

Insurance information:

Name:

Identification number:

Group number:

Customer service telephone number:

Claim address:

Why you are considering therapy right now?

What are your most important concerns?

If you had a magic wand, what would you wish for right now?

If this is for couples therapy, what are the major issues to focus on right away?

Have you ever utilized therapy before? What was your experience?

Have you used anti-depressant medication or other medications before? Please specify what, when and dosage.

Describe any concerns you have related to the following:

Thinking/concentration

Ability to focus

Complete tasks

Rapid heart beat

Panic attacks

Fears

Sleep

Eating

Anxiety

Depression

Low self-esteem

Sexual relations

Sexual orientation

Sexual identity

Suicidal thoughts or attempts

Homicidal thoughts or attempts

If you use alcohol or other drugs, describe your routine use. Be detailed.

Also, go to alcohol screening.org, complete the survey, add your score here:

Describe the family in which you were raised.

What were the major issues of concern in your family?

Who were you emotionally close to and emotionally separate from? Why?

How was the communication in your family?

Describe any times in your life where you felt mistreated or abused in any way. Start from when you first remember until the present time.

Go to the structured writing exercises and explore other questions which may relate to you.

Go to the help for Chicago marriages (relationships) category and explore some of those posts for help in either understanding a problem or finding a solution.

What else would you like to say about yourself, family or other significant relationships?

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