Grief Counselling Intake Form – Confidential Grief Counselling Intake Form – Confidential SECTION 1: PERSONAL INFORMATION User Code (Please do not include your name). * How old are you? * Birthday Address * Gender * Height (Feets) Weight (Kg) Referred By (Leave blank if you were not referred by anybody) Emergency Contact (Name) * Emergency Contact (Number) * Emergency Contact (Email) Relationship With Emergency Contact * SECTION 2: GRIEF COUNSELLING INFORMATION Why are you seeking help? * Please write in details to enable us to have an idea of how to help you efficiently Who are your primary sources of support? * So far, what solutions have helped you cope? * Who lives with you at the present time? * Kindly Include names, ages, and their relationship to you. If none, write NONE Current Symptoms Checklist (Please check all that applies to you) * Depressed mood Excessive worry Impulsivity Sleep pattern disturbance Loss of interest Decreased libido Concentration problems/forgetfulness Change in appetite Excessive guilt Decreased need for sleep Crying spells Increase risky behaviour Hallucinations Unable to enjoy activities Anxiety/ panic attacks Avoidance Increased libido Racing Thoughts Suspiciousness Excessive energy Increased irritability Excessive need for sleep Fatigue Lack of motivation How would you classify your eating habit? * Poor Excellent Good How would you classify your sleep? * Excellent Good Poor Have you ever had feelings or thoughts that you didn’t want to live? * No Maybe Yes Have you ever had feelings or thoughts that you would like to hurt someone? * No Maybe Yes Have you had any previous counselling experience? * No Yes If yes, kindly provide details (inclusive how the experience was for you) * SECTION 3: MEDICAL HISTORY List all current prescription medications and how often you take them: (if none, write none) * List all current over the counter medications and supplements and how often you take them: (if none, write none) * Current medical challenges (if none, write none) * Past medical challenges, nonpsychiatric hospitalization, or surgeries (if none, write none) * Do you have any concerns about your physical health that you would like to discuss with us? (if none, write none) * Has anyone in your family (immediate or extended) been diagnosed with or treated for (check all that applies) Alcohol Abuse Depression Anxiety Suicide/ Suicidal Thoughts Violence Bipolar Affective Disorder Other Substance Abuse Anger Management Post Traumatic Stress Disorder Schizophrenia Others SECTION 4: YOUR EXERCISE LEVEL Do you exercise regularly? * Yes No How many days a week do you get exercise? How much time each day do you exercise? SECTION 5: SUBSTANCE USE Have you ever been treated for alcohol, drug use? * Yes No If yes, for which substances? Please provide dates Check if you have ever tried any the following (check all that applies) LSD or Hallucinogens Alcohol Tranquilizer/sleeping pills Marijuana Tobacco (Cigarettes, pipes, cigar, or chewing) Cocaine Pain killers (not as prescribed) Methadone Methamphetamine Heroin Stimulants (pills) Ecstasy How many caffeinated beverages do you drink a day? Have people annoyed you by criticizing your drinking or drug use? Maybe Yes No Have you ever felt you ought to cut down on your drinking or drug use? Yes No Maybe Have you ever felt bad or guilty about your drinking or drug use? Maybe No Yes SECTION 6: FAMILY BACKGROUND AND CHILDHOOD HISTORY How much time did you spend with your immediate family when growing up? * Averagely Not so much Very much How many siblings do you have and what is your position in the family? * Did your parents’ divorce or seperate? * Yes No If yes, how old were you when they divorced or separated? If your parents divorced or separated, who did you live with while growing up? Describe your mother and your relationship with her growing up * Describe your father and your relationship with him growing up * Describe your relationship with your siblings growing up * Check any of the following that applied during your childhood/adolescence * Unhappy Childhood Alcohol Abuse Adventurous Legal Challenges Strong Religious Convictions School Challenges Drug Abuse Happy Childhood Emotional/ Behavioral Challenges Family Challenges Medical Challenges SECTION 7: RELATIONSHIP HISTORY AND CURRENT FAMILY Are you currently * Single Married Divorced Partnered Widowed Other How long? * Are you currently sexually active? * Describe your relationship with your spouse or significant other, if currently in a relationship (if none, write none) * Do you have children? * No Yes If yes, please list their ages * Describe your relationship with your child/ children (if any) SECTION 8: LEGAL/ FINANCIAL Do you have any pending legal problems? * No Yes Do you have any pending debt problems? * No Yes SECTION 9: SPIRITUAL LIFE Do you belong to a particular religion or spiritual group? * No Yes Do you find your involvement helpful during this trying period, or does the involvement make things more difficult or stressful for you? * Helpful Very much helpful Unhelpful Very much unhelpful Is there anything else that you would like us to know? (if none, write none) Where did you hear about us? * Friends and FamilyGoogle SearchInstagramFacebookYouTubeLinkedInReferral from a Professional (e.g. Doctor, Counsellor, Pastor, etc.)Others * I certify that the information provided on this form is true to the best of my knowledge * I acknowledge the use of the information provided on this form for my therapy sessions * I acknowledge that I have read and understand the informed consent (request a copy from the admin if you don’t already have one) Submit If you are human, leave this field blank. Δ
