Get Adult Intake Form - English - Wdmcp.com

Completing the Adult Intake Form online is an essential step in accessing counseling services. This comprehensive guide will provide you with clear instructions on filling out each section of the form accurately and efficiently.

Follow the steps to complete the Adult Intake Form online.

1. Press the 'Get Form' button to access the form and open it in the editor.
2. Begin with the demographic information section. Fill out your first name, middle name, nickname, and last name. Provide your date of birth in the mm/dd/yyyy format, gender, age, and ethnicity. Indicate your relationship status and employment details.
3. Continue to the contact information fields. Enter your home address, city, zip code, and phone numbers. Specify whether you allow contact via these numbers and if messages can be left. Also, provide your email address and specify email preferences.
4. Complete the emergency contact information by providing the details of someone who can be reached in case of emergencies. Include their name, address, phone numbers, and your relationship to this person.
5. In the presenting concerns section, list the reasons you are seeking counseling. You may provide up to five specific concerns.
6. Fill out the medical information section, which includes details about your primary care physician, previous counseling history, and any psychiatric history. Provide information regarding any medical conditions, medications, or allergies you may have.
7. Answer the questions related to substance use, indicating your use of caffeine, smoking, alcohol, and illicit drugs, if applicable.
8. In the referral information section, mention how you found out about the services. Indicate whether you were referred and by whom.
9. Fill out payment information, including how you plan to pay for services. Provide your insurance details if applicable, and review the agreements regarding payments and responsibilities.
10. Finally, review all your entries for accuracy and completeness. Once confirmed, save your changes, and you may download, print, or share the form as needed.

Complete your documents online now to ensure you are prepared for your counseling session.