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Broward Center for Counseling
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Adult Intake Form
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Adult Intake Form
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Adult Intake Form
About You
Your Name
(Required)
First
Middle
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
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Social Security Number
(Required)
Your Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Sex
(Required)
Male
Female
Marital Status
(Required)
Single
Married
Divorced
Widowed
Separated
Domestic Partnership
Cell Phone
(Required)
Home Phone
Preferred Phone
Cell Phone
Home Phone
Which number would you prefer we reach out to you at?
Email
EMERGENCY CONTACT
Name
(Required)
First
Last
Relationship
(Required)
Spouse
Domestic Partner
Father
Mother
Legal Guardian
Sibling
Grandparent
Phone
Alt. Phone
INSURANCE INFORMATION (PRIMARY)
Name of Insured
Insured's Date of Birth
MM slash DD slash YYYY
Untitled
Father
Mother
Legal Guardian
Sibling
Grandparent
Name of Carrier
Member ID
Group #
Employer Name/Company
Insurance Phone
Insurance Telephone for Customer Service/Mental Health Providers:
Do you have Secondary Insurance?
(Required)
Yes
No
INSURANCE INFORMATION (SECONDARY)
Name of Insured
Insured's Date of Birth
MM slash DD slash YYYY
Name of Carrier
Member ID
Group Member
Yes
No
Family History
WE BELIEVE WE CAN OFFER THE UTMOST QUALITY OF CARE BY WORKING AS A TEAM WITH YOUR OTHER HEALTHCARE PROVIDERS. PLEASE INITIAL BELOW: I AM WILLING TO ALLOW “BROWARD CENTER FOR COUNSELING” TO PROVIDE INFORMATION REGARDING MY CARE TO:
Religion: In Childhood
Religion: As an Adult
Mother
Mother's Status
(Required)
Living
Deceased
Mother's Current Age
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Mother's Age at time of Death
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Mother's Current Health
Mother's Occupation
Father
Father's Status
(Required)
Living
Deceased
Father's Current Age
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Father's Age at time of Death
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Father's Current Health
Father's Occupation
Siblings
Number of Sisters
(Required)
0
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Their Ages (Sisters)
Enter Ages (Example: 10, 11, 12)
Number of Brothers
(Required)
0
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10
Their Ages (Brothers)
Enter Ages (Example: 10, 11, 12)
Children
Number of Daugthers
0
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10
Their Ages (Daughters)
Enter Ages (Example: 10, 11, 12)
Number of Sons
0
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Their Ages (Sons)
Enter Ages (Example: 10, 11, 12)
Clinical Data
ON THE SCALE BELOW PLEASE ESTIMATE THE SEVERITY OF YOUR PROBLEM:
Mild
Moderate
Extreme
GIVE A BRIEF DESCRIPTION OF THE HISTORY AND DEVELOPMENT OF YOUR CONCERNS (FROM ONSET TO PRESENT)
THE NATURE OF YOUR CONCERNS AND THEIR DURATION, WHICH HAVE LED YOU TO SEEK COUNSELING AT THIS TIME
PLEASE LIST ANY THERAPIST OR PSYCHIATRIST WHOM YOU HAVE CONSULTED
Are you taking any Medication? If Yes, What, How Much, and What Results?
Primary Physician Name
Primary Physician Phone
Current Psychiatrist Name
Current Psychiatrist Phone
Can We Work With Your Physicians?
Yes
No
Which Doctor Can We Work Together With?
Primary Care Physician
Psychiatrist
Financial Responsibility
I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT ON MY ACCOUNT AND THAT “BROWARD CENTER FOR COUNSELING” WILL VERIFY MY INSURANCE BENEFITS AS A COURTESY. I UNDERSTAND THAT I WILL BE HELD RESPONSIBLE FOR ANY OFFICE CHARGES NOT PAID BY MY INSURANCE COMPANY.
Signature
Date
MM slash DD slash YYYY
CAPTCHA
Email
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