Adult Intake Form Name Date of Birth Sex SexMaleFemale Phone Number Email Address Address City ZIP Religious Affiliation Employer Work Phone Work Address Work City Work Zip Family Information Family InformationSingleMarriedSeparatedDivorcedWidowedLiving Together Name of Spouse/Significant Other Child 1 Name Child 1 Age Child 1 Grade Child 1 Biological/Adopted Child 1 Biological/AdoptedBiologicalAdopted Child 2 Name Child 2 Age Child 2 Grade Child 2 Biological/Adopted Child 2 Biological/AdoptedBiologicalAdopted Child 3 Name Child 3 Age Child 3 Grade Child 3 Biological/Adopted Child 3 Biological/AdoptedBiologicalAdopted Child 4 Name Child 4 Age Child 4 Grade Child 4 Biological/Adopted Child 4 Biological/AdoptedBiologicalAdopted Name of anyone else living in the home Physician’s Name Date of Last Physical Are you currently being treated for any medical conditions? Are you currently being treated for any medical conditions?YesNo If yes, please explain: Are you currently taking any medications? Are you currently taking any medications?YesNo If yes, please list: Please list any allergies: Have you received previous counseling? Have you received previous counseling?YesNo If yes, by whom and when? Please briefly state why you are currently seeking counseling: Referred By Referral Address I would like to send a note of appreciation to the person who referred you for supporting our ministry. I would like to send a note of appreciation to the person who referred you for supporting our ministry.YesNo I authorize Winning At Home Family Wellness Center to use the email and mobile number listed above to send changes and/or confirmations to my appointment schedule via text message or voice mail. I authorize Winning At Home Family Wellness Center to use the email and mobile number listed above to send changes and/or confirmations to my appointment schedule via text message or voice mail.YesNo Emergency Contact Name Emergency Contact Phone Number Emergency Contact Relationship to Client 6 + 14 = Submit
