Intake Questionnaire

Thank you in advance for completing the following form.  This information you have provided will help our staff create a plan tailored to meet your needs and those of your family.

Today's Date
Your Name:
Your present age:
Your Gender:Male  Female
Your Racial or Ethnic origin:
American Indian Alaskan Native Asian or Pacific Islander Black Hispanic White Other
Your highest level of education that you have completed
Some High School Completed High School Some College Completed College Some Graduate Work Graduate Degree
Your present employment status
Employed Full Time Employed part time Unemployed Retired Student Full time homemaker
You are currently    
Single Engaged Cohabitating Married Separated Divorced Remarried Widowed
Please provide the following information about your children:
1st child's name  Age:
2nd child's name  Age:
3rd child's name   Age:
4th child's name   Age:
5th child's name   Age:
6th child's name   Age:

Are you a church member?    Yes  No   Looking
What church?

Are you a Christian?  Yes No Interested
When did you become a Christian?
Describe the events or circumstances that brought you to the place to ask Christ to enter you life.

Have you been in treatment before?  Yes   No

What were the circumstances?

What was the outcome?

To better understand your present situation and complete this assessment please select the scale below fill it out and submit it along with this intake form.  You may complete as many forms as best describes you.

DIAGNOSTIC CRITERIA FOR ATTENTION DEFICIT DISORDER (ADD AND ADHD) IN ADULTS
These two tools are used to assess adult ADHD

Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder in Children
Fill this out for a diagnosis of ADHD and ADD in Children

The Homes Rake Stress Scale of Change  
A very accurate way to evaluate the amount of stress you have encountered during the last year

INDEX OF SEXUAL SATISFACTION (ISS)
Complete this scale to assess your sexual satisfaction

INDEX OF MARITAL SATISFACTION (IMS)
Complete this scale to assess your marital satisfaction

INDEX OF PARENTAL ATTITUDES (IPS)
Complete this scale to assess your attitudes as a parent/step parent

INDEX OF SELF-ESTEEM (ISE)
Complete this scale to assess your self image or self esteem

INDEX OF FAMILY RELATIONS (IFR)
Complete this scale to assess the quality of your family relations

CLINICAL ANXIETY SCALE (CAS)
Complete this scale to assess your level of anxiety

GENERALIZED CONTENTMENT SCALE (GCS)
Complete this scale to assess your contentment or level of depression

Conner's Teachers Questionnaire for ADHD in Children

Conner's Parents Questionnaire for ADHD in Children