Get Counseling Office Intake Form

The Counseling Office Intake Form is a crucial document that provides essential information for your genetic counseling session. Completing this form accurately online ensures that you receive the most appropriate support tailored to your needs.

Follow the steps to fill out the Counseling Office Intake Form effortlessly.

1. Click ‘Get Form’ button to access the Counseling Office Intake Form and open it in your preferred editor.
2. Begin by entering the patient’s name in the designated field. Ensure it is spelled correctly to avoid any issues in records.
3. Next, provide the date of birth for the patient in the format specified in the form.
4. Continue by filling in the husband/partner’s name and their date of birth accurately.
5. If you are currently pregnant, enter the first date of your last menstrual period in the appropriate field.
6. Indicate whether you have had an ultrasound during this pregnancy by selecting 'Yes' or 'No'.
7. Fill in your due date in the specified field.
8. Record the total number of pregnancies you have had, including the current one.
9. Provide details for full-term and preterm deliveries by entering the respective numbers.
10. If applicable, list the names and ages of your children in the specified fields, including any miscarriages or stillbirths.
11. Mention any health problems of your husband/partner’s children if they are from another relationship.
12. Respond to questions about family health history, including birth defects and chromosome abnormalities, selecting 'Yes' or 'No' as appropriate.
13. If you answered 'Yes' to any of the previous questions, please explain further in the provided space.
14. List your ancestry and your partner’s ancestry in the designated fields.
15. Indicate if you or your partner have undergone genetic testing for conditions like sickle cell trait, cystic fibrosis, and provide the results.
16. Answer questions regarding your current or past health issues by selecting 'Yes' or 'No', and explain if applicable.
17. Address the health concerns you experienced during this pregnancy by answering each question with 'Yes' or 'No'.
18. If you smoke, provide the number of cigarettes you smoke per day; if you consume alcohol or use any illicit drugs, provide details as required.
19. If applicable, specify any relation between your family and the father of the baby’s family before marriage.
20. Finally, list any additional questions or concerns you wish to address during the counseling session in the space provided.
21. After completing all sections of the form, review your entries for accuracy, then save your changes. You can also download, print, or share the form as needed.

Ensure your documents are completed online for a smoother counseling experience.