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Pathways | Forensic & Mental Health | Lufkin & Nacogdoches
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About Dr Jean Stanley
Our Providers
Monica Oliver, MA, LPC
Brandy Goins, MS, Ph.D. (abd), LPC, LSOTP, CTHP
Jen LoStracco, MA, LPC
Joe R Morales, MA, LPC
Angela Cooper MA, LPC
Dr. Shannon Matthews, LPCS, NCC
Bonnie Stephens, LPC, NCC
Our Services
Professional Psychotherapy & Assessment Services at Pathways
Forensic Psychological Services
Pre-bariatric Surgery Psychological Evaluation
Forms
Locations
Blog
Contact Us
Book an Appointment
Home
About Dr Jean Stanley
Our Providers
Monica Oliver, MA, LPC
Brandy Goins, MS, Ph.D. (abd), LPC, LSOTP, CTHP
Jen LoStracco, MA, LPC
Joe R Morales, MA, LPC
Angela Cooper MA, LPC
Dr. Shannon Matthews, LPCS, NCC
Bonnie Stephens, LPC, NCC
Our Services
Professional Psychotherapy & Assessment Services at Pathways
Forensic Psychological Services
Pre-bariatric Surgery Psychological Evaluation
Forms
Locations
Blog
Contact Us
Book an Appointment
Home
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Forms
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Adult Client Intake Form
"
*
" indicates required fields
CLIENT INFORMATION (Person receiving services)
Name
*
Date
*
Address
*
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
*
Home
*
Work
Cell
Date of Birth
*
Age
*
Social Security Number
*
Emergency Contact
*
Phone
*
EMPLOYER INFORMATION
Employer
*
Position/Grade
*
For How Long?
*
Education Level
*
Insurance
*
Policy #
*
Group #
*
Policy Holder
*
Policy Holder DOB
*
Relationship to Client
*
FAMILY INFORMATION
Marital/relationship status
*
Single
Married
Divorced
Separated
Widowed
if separated / divorced, how long?
Spouse/Significant other’s name
*
Significant Other’s Age
*
Significant Other’s Sex
*
Male
Female
Other
How long together?
*
Children, Age, In Home
Children
Child Name
Child Age
In Your Home?
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Remove
MEDICAL INFORMATION
Name of primary care physician
*
Address
*
Phone
*
Fax
Last medical evaluation (date)
*
Next appointment (date)
*
Other physicians you see / Reason
*
Please List Physician Name - and Reason
List any allergies you have:
Type "None" if you have none.
Please list all current medications and dosages:
Medication
Dosage
Prescribing Doctor
Start Date
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Remove
Please list all current health problems
*
Please list all past health problems and major operations.
*
Have you ever been hospitalized for medical or psychiatric reasons?
*
Yes
No
List Hospitals
Hospital name/address
Date
Reason
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Remove
MENTAL AND EMOTIONAL HEALTH
Have you ever been in counseling/therapy for any reason?
*
Yes
No
List Counselors
Counselor name/address
Date
Reason
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Remove
Are you currently seeing any other therapist?
*
Yes
No
If so, Therapist Name:
Reason for Current Treatment
Have you ever considered suicide?
*
Yes
No
In connection to your current problems?
*
Yes
No
If yes, please describe when and what you considered:
In connection to your past problems?
*
Yes
No
If yes, please describe when and what you considered:
Have you attempted suicide recently or in the past?
*
Yes
No
If yes, please describe when and what you considered:
Have you had any thoughts of hurting others recently or in regard to your current problems?
*
Yes
No
If yes, please explain
Have you had any thoughts of hurting others in the past?
*
Yes
No
If yes, please explain
CURRENT
*
Very Unhappy
Short Attention Span
Grief
Impulsive
Mood Swings
Fearful
Irritable/Angry
Self-Mutilating
Parenting Issues
Anxious
Intrusive Thoughts
Trauma
Worried
Alcohol Use
Relationship Issues
Temper Outburst
Drug Use
Abuse Victim
Behavioral Problems
Lethargic, No Energy
Suicidal Thoughts
Lying
Sleeping Problems
Low Self-Esteem
Withdrawn
Eating Problems
Divorce
Panic Attacks
Intimacy Issues Hallucinations/Delusion
Excessive Crying
Trust Issues
Educational Issues
PAST
*
Very Unhappy
Short Attention Span
Grief
Impulsive
Mood Swings
Fearful
Irritable/Angry
Self-Mutilating
Parenting Issues
Anxious
Intrusive Thoughts
Trauma
Worried
Alcohol Use
Relationship Issues
Temper Outburst
Drug Use
Abuse Victim
Behavioral Problems
Lethargic, No Energy
Suicidal Thoughts
Lying
Sleeping Problems
Low Self-Esteem
Withdrawn
Eating Problems
Divorce
Panic Attacks
Intimacy Issues Hallucinations/Delusion
Excessive Crying
Trust Issues
Educational Issues
What, if any of these problems/symptoms/ situations do you want or need to address?
*
SUBSTANCE USE/ABUSE HISTORY
Please indicate which of these substances you currently use:
*
Substance
Amount used
How often?
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Remove
Is your counseling court-related?
*
Yes
No
COURT-RELATED CLIENTS:
*
pre-Trial Criminal Case
Charge
*
pre-Sentence Status
Charge
*
Post-Conviction Criminal Case
Charge
*
Family Law Litigation
Charge
Attorney’s Name
*
Address
*
Arrests
List the charge(s) for which you are on probation, parole, or any charges still pending in the Court
Date of arrest
Probation Officer
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Remove
Please provide details below
What are your primary goals for therapy?
*
Payment Policy
*
I Agree
I hereby consent for Pathways FMHS to provide evaluation and treatment services and release diagnostic codes and sessions dates to insurance if needed for billing purposes.
Client Name
*
Date
*
GENERAL CONSENT FOR USE OF ELECTRONIC MEDIA:
Email Address
*
May we email you at this address?
*
Yes
No
Home Phone Number
*
May we leave messages at this number?
*
Yes
No
Cell Phone Number
*
May we leave messages at this number?
*
Yes
No
By my signature, I am acknowledging that I have been made aware that Pathways Forensic & Mental Health Services is not using a private / encrypted server for the exchange of email; therefore, any use of email on my part to Pathways FMHS, or that of the therapist regarding my treatment, may be transmitted through a server that is not secure; therefore, may not be confidential. If you answer “Yes” to communicate by email, and/or text, you must sign this acknowledgement and consent.
With my signature, I am acknowledging that I have read and understand this disclosure and do, hereby, authorize Pathways to contact me in the manners designated above.
Client (or Parent/Guardian of Minor)
*
Date
*
MM slash DD slash YYYY
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