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Pathway Guidance Services, LLC Individual Counseling Intake Form

Date

Month

Day

Year

Section 1: Personal Information

First name

Last name

Birthday

Month

Day

Year

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Contact

Section 2: Insurance Information

Primary Insurance Company

Policy Number

Group Number

Relationship to Client

Briefly describe the main signs, that lead you to seek counseling:

Section 3: Presenting Issues

How long have these issues been bothering you?

What would you like to gain or achieve through counseling?

Section 4: Mental Health and Medical History

Have you previously received counseling?

Yes

No

If yes, when and for what reason

Have you ever been diagnosed with a mental health condition? If yes, please specify

Yes

No

Current medications (if any)

Any significant medical conditions?

Yes

No

Current Medication, If any

Any past or present thoughts of self-harm or suicide? If yes, please describe briefly:

Yes

No

Any significant medical conditions? If yes, please list

Section 5: Substance Use

Do you currently use any of the following? (Check all that apply)

Alcohol

Tobacco

Marijuana

Prescription drugs (non-prescribed)

Recreational drugs

Other

Frequency of use:

Section 6: Family & Support System

Describe your current living situation (e.g., live alone, with family, etc.):

Who do you turn to for emotional support?

Any family history of mental health issues? (If yes, Explain)

Yes

No

Section 7: Counseling Goals

Goal 1

Goal 2

Goal 3

Section 8: Consent & Signature

I understand that the information provided in this form is confidential and will be used for treatment planning and therapeutic purposes only. I agree to participate in counseling voluntarily and understand I may withdraw at any time.

Signature

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Date

Month

Day

Year

2025.PATHWAY GUIDANCE SERVICES,LLC / ALL RIGHTS RESERVED.

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