Crisis Counseling Intake Questionnaire

Client Information

Full Name Date of Birth Phone Number Email Address Address

Emergency Contact

Name Phone Number Relationship

Presenting Crisis

Please describe the crisis or main concern How long has this been an issue? Any recent significant events?

Risk Assessment

Are you having thoughts of harming yourself? Yes No Are you having thoughts of harming others? Yes No Do you have a support system? Yes No

History

Previous mental health diagnosis or treatment? Current medications Any medical conditions? Substance use concerns?

Other Information

Additional comments / concerns