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上传于：2016-03-21

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    188宝金博页面版: docx - Arrow Counseling Services

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    内容提示： Arrow Counseling Services, LLC CONFIDENTIAL ADULT CLIENT INTAKE FORM Today’s Date: ___________________________ Name: ______________________________________________ Date of Birth _______________________ SS#: ________________________________________________ Gender: Male Female (Circle One) Address: __________________________________________________ Age:_____________ ___________________________________________________ How would you like me to contact y...

    文档格式：DOCX | 页数：14 | 浏览次数：68 | 上传日期：2016-03-21 21:08:39 | 文档星级：
    Arrow Counseling Services, LLC CONFIDENTIAL ADULT CLIENT INTAKE FORM Today’s Date: ___________________________ Name: ______________________________________________ Date of Birth _______________________ SS#: ________________________________________________ Gender: Male Female (Circle One) Address: __________________________________________________ Age:_____________ ___________________________________________________ How would you like me to contact you? (Please circle response) Home: yes or no Phone: Work: yes or no Phone: Cell phone: yes or no Phone: Email: yes or no Email address: Other: PRESENT ISSUES AND GOALS Please describe why you are coming to counseling. How long has this been going on? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ What do you hope to gain from this counseling experience? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Please check any of the following symptoms or problems that you currently are or recently have experienced: ? Stress? ? Marital Problems? Compulsive Behaviors? ? Anxiety?? Other relational problems? ? Hallucinations? Panic? ? Physical Abuse?? Hearing Voices? ? Depression? Emotional Abuse? ? Racing thoughts?? Apathy? ? Verbal Abuse? Eating problems? ? Fatigue/Lack of energy?? Sexual Abuse? ? Drug use? Loss of Appetite/Overeating?? Sexual Problems?? Alcohol Use? ? Trouble sleeping? Gender Identity Issues? ? Pregnancy?? Poor concentration? ? Anger? Abortion? ? Feeling worthless?? Aggressive behavior? ? Legal matters? Recent death? ? Bad dreams?? Work stress? ? Grief? Unwanted memories? ? Career choices?? Chronic pain? ? Loss of control? Indecisiveness? ? Lonliness?? Impulsive behaviors? ? Parenting problems? Fears? ? Controlling?? Financial problems? ? Shyness? Controlled by others? ? Spiritual problems?? Low self esteem? ? Obsessive thoughts? Cutting/self harm? ? Other: _________________Please circle the number that best indicates how distressing your problems are to you currently 1 2 3 4 5 6 7 8 9 10 Minimally distressed Moderately distressed Extremely distressed

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