EACH PERSON ATTENDING COMPLETES A SEPARATE INTAKE FORM.
Community Wellness Partners of NC PLLC
809 N. Lafayette St., Suite A, Shelby, NC 28150
1446 E. Gaston St. Suite 101, Lincolnton, NC 28092
Phone: (704) 284-0554
Email: info@cwpofnc.com
CONFIDENTIAL CLIENT INFORMATION
Date:
Social Security Number:
First Name:
Middle Name:
Last Name:
Date of Birth:
Age:
Highest Grade Completed:
Address:
City:
State:
AA
AE
AK
AL
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WV
WI
WY
ZipCode:
How do you prefer we contact you?(Mark all that apply)
Mail
Email
Telephone
Text Message
Only Add Numbers that you want to receive a message to: (voice/text)
Home Phone:
Cell Phone:
Work Phone:
Primary Email:
Gender:
Sexual Orientation:
Race:
Marital Status:
Employment Status:
Employed
Unemployed
Student
Retired
Disabled
Other
Occupation:
Active Military Status:
Primary Language:
Religious Preference:
Living Arrangement:
Homeless
Foster Home
Private Residence
Nursing Home
Group Home
Legally Responsible Person
( For Minor Clients)[SWTC must have a copy of official custody documents on file prior to serving a minor]
Name:
Relationship:
Emergency Contact Name:
Emergency
Contact Relationship:
Emergency
Contact Date of Birth:
Emergency
Contact Phone #:
Please check all that apply in your
current
family
(only
yourself, spouse, and/or kids).
History of:
Suicide
Alcoholism
Substance Abuse
Mental Illness
Domestic Violence
Sexual Abuse
Other:
Please check any/all that apply
anywhere
in your family tree
(your parents, relatives, spouse's family, etc.).
History of:
Suicide
Alcoholism
Substance Abuse
Mental Illness
Domestic Violence
Sexual Abuse
Other:
Current Medications, include name of medication, start date, reason, dosage, and prescribing doctor:
Please list previous counseling, include name, dates attended, reason and diagnoses
Please briefly describe what you hope to accomplish as a result of working with your therapist:
Please briefly describe why you chose SWTC over another therapy practice:
How did you come to hear about Shelby Wellness and Therapy Center? (check all that apply)
Referrals
Ads
Flyers
Family
Friend
Other:
Please list below any internet search engines or websites you visited in your therapist search:
Google
Psychology Today
ShelbyTherapy.com
Other:
Please check any/all issues which are a concern for you today:
Abortion
DSS Involvment
Insomnia
Repetative Behaviors
Adoption
Eating Habits
Learning Difficulties
Self-Confidence
Alcohol Use
Education
Legal Issues
Self-Control
AmbitionList
Emotional Abuse
Legal Problems
Self-Esteem
Anger
Energy Level
Loneliness
Self-Injurious Behaviors
Anxiety
Exhaustion
Marital Problems
Sexual Abuse
Appetite
Family Problems
Marital Seperation
Sexual Addiction
Argumentative
Fears
Memories
Sexual Orientation
Attention Problems
Finances
Motivation
Sexuality
Children
Fire Setting
My Thoughts
Shyness
Chronic Pain
Focusing Problems
Nail-biting
Smoking
Codependency
Friends
Nervousness
Social Anxiety
Communication
Gambling
Nightmare
Spirituality
Concentration
Gender Identity
Obessive Thoughts
Stealing
Constant Conflict
Guilty Feelings
Overweight
STI/STD
Crying
Headaches
Panic Attacks
Stress
Death of a loved one
Health
Parenting
Suicidal Thoughts
Decision Making
Hyperactivity
Perfectionism
Temper
Depression
Incest
Physical Abuse
Traumatic Event
Divorce
Inferiority
Pornography
Underweight
Domestic Violence
Infertility
Procrastination
Unhappiness
Drug Abuse
Infidelity
Rape
Work
What do you consider your strengths?
What do you consider your areas of improvement?