Intake Form | ABIDE Network

Address of Spouse

List children and ages, if any.

Is faith an important part of your life? Explain:

List all important past injuries or handicaps:

Do you have any current medical conditions? If so, please explain:

List all important past mental health problems you’ve experienced:

Do you have a history of suicide attempts? If so, please explain:

Do you currently suffer with any psychotic episodes? If so, please explain:

Do you have any current mental health diagnoses? If so, please explain:

Please provide contact information for any current medical providers (address & phone number).

Please list any medication, dosage, frequency and for which conditions.

Have you ever used drugs for purposes other than medical? If yes, explain:

Use this field to give more details.

Date, provider, level of care, duration, condition (MH/SA), outcome.

Is there anything else significant about your childhood that you feel would be helpful to mention at this time?

Please write a paragraph or so about what leads you to seek counseling. What symptoms are you experiencing? What kind of interpersonal problems would you like to solve? Please give all relevant information.

Abide Network Intake Form