Form ~ Client Intake

The Esposito Institute, Inc.

Your Name:                                Today’s Date:   

Mail Address:
Email address:                                           

Your Website:

Work Phone:                                 Home Phone:
       
Cell Phone:                             

Which number do you prefer Benita to call?   
     
Does Benita have permission to leave a message for you on your answering service or with a family member? __ yes     __ no

Your Age:             Birth date:             

Religious/spiritual preference, if any:

Check all that apply:  __ married   __living together   __dating  __ engaged  __ single  __ divorced  __ widowed

Number of marriages ___       

Your mate’s name:                                              

How long have you been together?

Names and ages of children:

Please contact these people in the event of an emergency:

Name:     

Phone:                               Relationship to you:

Name:                        

Phone:                              Relationship to you:

Please check the topics that interest you.

 
___ Creating healthy personal relationships               
___ Stress management
___ Creating healthy professional relationships        
___ Relaxation or meditation skills  
___ Increasing prosperity        
___ Reducing loneliness
___ Ending a relationship or a divorce well       
___ Work as an expression of your soul
___ Intimacy and sexuality as a spiritual path       
___ Balancing personal and professional life
___ Mind / Body / Spirit Healing       
___ Mid-life issues
___ Parent-Child relationships: your parents or kids        
___ Eliminating addictions  
___ Communication skills and conflict resolution       
___ Healing trauma and abuse
___ Pre-marital counseling
___ Pre-engagement counseling       
___ Healing grief and loss
___ Reducing anxiety       
___ Reducing depression
___ Healing my physical body                   
___ Spiritual Development
___ Weight Management                       
___ Adjusting to divorce

Briefly describe your reason(s) for seeking help. 

 

How long have you had the problem(s)?


What prompts you to seek help now?


What other ways have you tried to deal with this problem?


Your Goals:  What do you want to experience and accomplish in therapy?  Please be as specific as possible.



What length of time do you want to take to create these results?  _____  

How often do you want sessions? _______

What kind of sessions do you want?  
___ individual 
___ couples   
___ family     
___ group    
___ educational workshops    
___ retreats

Are you currently seeing a psychotherapist or psychiatrist?  ___ yes  ___ no
 
Therapist name _________________________________

Phone ______________________ 

Dates in treatment _________________

Psychiatrist’s name  ______________________________

Phone ______________________ 

Dates in treatment _________________

Past Inpatient treatment   ___ yes  ___ no         

Where _______________________

When ________________________

How long ______________
 
Past outpatient treatment   ___ yes  ___ no         

Did it help?   ___ yes  ___ no

Family history of emotional problems   ___ yes  ___ no     

Who ______________________

Relationship to you  ___________________

What type of problems?


Medication and Supplement Information
List all of the prescription and over-the-counter drugs you are taking. Include vitamins, minerals and homeopathics.



 
Health Status

List any medical problems or physical problems and when they were diagnosed.
1.
2.
3.
List any major (where you were put to sleep) surgeries you have had to date.
1.
2.
3.
List any serious illness or injuries especially anything involving the head.
1.
2.
3.

List any specific concerns you have about coming to counseling:


Print Client Name

____________________________________________
 
Client Signature 

____________________________________________         
 

Date  __________________________________