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Click ‘Get Form’ to open the SMT Client Intake Form in the editor.
Begin by filling in the 'Date of Intake' and selecting the 'Type of Intake' as either NEW or RE-ADMISSION. Enter your 'Client Number' if applicable.
In the 'CLIENT INFORMATION' section, provide your name, date, gender, age, date of birth, address, contact phone number, email, employer, occupation, and marital status. Ensure all fields are completed accurately.
For 'FAMILY DYNAMICS', list relationships and details about family members. Check boxes for living arrangements and note any significant family events.
Complete the 'COUNSELING HISTORY' section by indicating previous counseling experiences and any mental health hospitalizations. Provide explanations where necessary.
Rate current symptoms in the 'CURRENT SYMPTOMS CHECKLIST'. Use the provided scale to indicate severity for each symptom listed.
Fill out the 'SUBSTANCE USE HISTORY' section with details on substance use frequency and history. Indicate if you have sought help for substance abuse.
Provide your medical history including primary care provider information and any prescribed medications. List any health concerns or past surgeries.
Identify treatment goals in the designated area to specify what you wish to work on during counseling sessions.
Finally, review the CLIENT NOTIFICATION OF PRIVACY RIGHTS and sign at the bottom to confirm understanding before submitting your form.
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What 5 forms of information should clients be provided with in an intake?
What 5 forms of information should clients be provided with in an intake? Scope. Clearly outline the legal services the firm will provide, including specific tasks and objectives related to the clients case. Fee structure. Billing. Client responsibilities. Confidentiality and communication.
What are the components of a client intake form?
Elements of a Client Intake Form Client Information: Enter the clients name and other details, if applicable (e.g., date of birth, age, gender, etc.). Contact Information: Enter the clients contact information (e.g., address, phone number, email, etc.). Date: Enter the date of the client intake.
How do I create a therapy intake form?
Essential components of an effective therapy intake form Patient demographics: Basic information such as name, age, gender, and contact details. Medical history: Including past medical conditions, surgeries, and allergies. Reason for seeking therapy: Understanding the patients primary concerns and goals for treatment.
How to make a client intake form on Google Docs?
Navigate to your Google Forms. Click the Blank form button to start a new form. Title your form appropriately and also offer a helpful description for your recipients. Edit the default, untitled question to gather the name of your client/customer/patient. Select the Short answer question format.
How do I create a client intake form in Word?
Intake forms can be made in Word by following these steps: Step 1 : Open Microsoft Word. Step 2 : Make a new document. Step 3: Add form fields. Step 4: Customize the details of the form. Step 5: Keep the form safe. Step 6: Send it out and save it.
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Intake forms examples and templates you can use for your clients Basic information: Full name. Company name. Contact details (phone, email, address) Service requirements: Type of service required. Goals or expectations from the service. Budget (optional) Additional notes or questions: Free text field.
How do I create a client intake form?
Create a client intake form using a fillable PDF. Launch Acrobat. Click Tools Prepare Form. Select a file or scan a document. Add new form fields. These form fields can ask for a name, email, reason for requesting services, and more. Click Distribute to collect responses automatically.
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