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Adult Pre-Intake Questionnaire

Thank you for choosing Northland Counseling Center, Inc! Please complete the below form as part of our intake process or for our annual update. Any missing information may cause a delay in services. Along with this form please ensure you are also filling out these additional forms:

Adult Registration Form
PHQ-9
GAIN-SS
GAD-7
WHODAS
Provider Supervision Form
Medicare Beneficiary Notice– If you have Medicare as an insurance plan, please review

We have been notified of a few issues with form submissions, We apologize for any inconvenience. This is currently being worked on. If you fill out the information below; please make sure you click yes to the hipaa privacy statement and the RED submit button. If there is an issue, please email bworrath@northlandcounseling.org with a picture or description of the error that occurred. We are working on correcting the issue. Thank you!

if the page is blue, scroll to the bottom and click on desktop version. otherwise, the page will not submit.

Adult Pre-Intake Questionnaire

Adult Pre-Intake Questionaire

Today's Date:

MM slash DD slash YYYY

Location for which you would like your services at:

Grand Rapids

Hibbing

Aitkin

International Falls

Client Name:

First Middle Last

Address:

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone:

May we leave a voice message?

Yes

No

May we text?

Yes

No

Email:

May we email you?

Yes

No

Gender:

Male

Female

Non-Binary

Date of Birth:

MM slash DD slash YYYY

Age:

Social Security Number:

Race:

Asian

Black/African American

Native Hawaiian

White

Other

American Indian / Alaskan Native

If your race is Native American / Alaskan Native please indicate Tribal Enrollment:

Ethnicity:

If you are Hispanic/Latino, Please indicate one of the following:

Not Hispanic / Latino

Central American

Cuban

Dominican

Puerto Rican

South American

Other

Hair Color:

Hair Length:

Short

Medium

Long

Eye Color:

Do you wear...

Eye Glasses

contacts

Neither

Weight:

Height:

Military Service:

Non-Vet

Vietnam Vet

Other Vet

Disabled

I did NOT serve in the Military

If you did serve, what Branch:

Emergency Contact:

Emergency Contact Name:

First Last

Emergency Contact Address:

Street Address City State / Province / Region ZIP / Postal Code

Phone

Relationship:

Guardian / Power of Attorney

Do you have a Guardian?

Yes

No

Do you have a Power of Attorney?

Yes

No

Power of Attorney:

First Last

Power of Attorney Phone Number:

Power of Attorney Email

Guardian:

First Last

Guardian Phone Number:

Gaudian Email

Reason for Visit:

Tell us who referred you:

Self-Referred

Referred by a Health Care Provider / Mental Health Provider

Court

Chemical Dependency / Drug Court

Employment Requirement

Other

Please explain the reason(s) you are seeking mental health services:

Current Life Situation:

Marital Status:

Single / Never Married

Married

Divorced

Re-Married

Separated

Living with significant other (boyfriend/girlfriend/fiancé)

Spouse / Significant Other name:

First Last

Where do you live?

Apartment

House

Residential Facility / Community Residential Setting

Homeless

Other

Who do you reside with?

Alone

Spouse

Parents

Children

Friends

How long have you lived at your current location?

Name of other individuals in the house, if applicable:

First Last

Age:

Relationship:

Name of other individuals in the house, if applicable:

First Last

Age:

Relationship:

Name of other individuals in the house, if applicable:

First Last

Age:

Relationship:

Name of other individuals in the house, if applicable:

First Last

Age:

Relationship:

Name of other individuals in the house, if applicable:

First Last

Age:

Relationship:

Name of other individuals in the house, if applicable:

First Last

Age:

Relationship:

How would you describe your living situation?

Excellent

Good

Okay

Poor

Income and Employment:

Current Source of Income:

Wages

Social Security

Pension

MFIP

Child Support

Other

Occupation:

Employment:

Full-Time

Part-Time

Seasonal

Self-Employed

Disabled

Retired

Unemployed

Student

Employer's Name:

Education History:

Education:

Currently in Grade School, Middle School or High School

GED

High School / Diploma

Vocational Certificate

Some College

College Graduate

Post Graduate

Did NOT complete school

Degree OR Current Grade of school currently enrolled in:

Highest High School Grade Completed:

If you answer 'yes' to receiving Special Education Services, Please tell us what services (IEP, 504) and why:

Did you receive Special Education Services?

Yes

No

I am NOT sure

Barriers to learning or past school testing:

Additional Comments / Information about Educational Barriers or Educational History:

Symptoms / Relevant History (Northland will NOT be contacting other providers unless given permission):

Please let us know what symptoms you may be experiencing:

Anxiety

Worry Thoughts

Racing Heart

Depressed Mood

Irritable Mood

Sleeping Too Much

Isolating

Concentration

Attention

Inability To Follow Instructions

Nightmares

Vomiting

Restricting Food Intake

Difficulties with Relationships

History of Abuse (physical, mental, sexual)

Impulsivity

Intense Anger

Experienced a Traumatic Event

Difficulties with Authority Figures

Have you completed a diagnostic assessment (DA) within the past year:

Yes, please list

No

I am NOT sure

Agency

Date of last know appt:

MM slash DD slash YYYY

Have you ever received Mental Health (Therapy) Services in the past?

Yes, please see below

No

I am NOT sure

Agency

Date of last know appt:

MM slash DD slash YYYY

Have you ever received Medication Management from a Psychiatrist or Nurse Practitioner?

Yes, please see below

No

I am NOT sure

Agency

Date of last know appt:

MM slash DD slash YYYY

Do you have a Psychiatric Health Care Directive:

Yes

No

I am NOT sure

Early Childhood Developmental Concerns:

Do you have concerns with development, nutrition and/or social concerns, please indicate concerns in as much detail as possible:

Normal Birth?

Yes

No

Please list any birth complications or birth defects:

Were early childhood milestones met on time?

Yes

No

Please list any developmental delays (walking, talking, dressing, toileting, etc):

Please list any special needs in childhood:

Substance or Alcohol Abuse History (Northland will NOT contact any providers unless given permission):

Have you ever participated in Substance Abuse Treatment?

Yes, please see below

No

I am NOT sure

Agency

Date of last know appt:

MM slash DD slash YYYY

Agency

Date of last know appt:

MM slash DD slash YYYY

Do you feel you have a problem with substances and/or alcohol?

Yes

No

I am NOT sure

If yes, please describe:

If yes, do you want help with substance use?

Yes

No

I am NOT sure

Any Family History of Substance or Alcohol Abuse / Dependence?

Yes

No

I am NOT sure

Do you use Alcohol?

Yes

No

How often do you consume Alcohol and How much Alcohol do you consume?

Do you use Tobacco?

Yes

No

How often do you consume Tobacco and How much Tobacco do you consume?

Do you use Caffeine?

Yes

No

How often do you consume Caffeine and How much Caffeine do you consume?

Do you use Marijuana?

Yes

No

How often do you consume Marijuana and How much Marijuana do you consume?

Do you use Other - (ecstasy, meth, inhalants, cocaine, etc)?

Yes

No

How often do you consume Other and How much Other do you consume?

Non-medical use of prescribed or over-the-counter drugs (Vicoden, Percocet, Ritalin, etc.)??

Yes

No

How often do you consume Non-Prescribed / Over-the-Counter and How much Non-Prescribed / Over-the-Counter do you consume?

Medical (Northland will NOT contact any providers, unless given permission)

List significant current or past medical conditions:

Have you had your thyroid checked?

Yes

No

If known, what is the Date of your past thyroid check?

MM slash DD slash YYYY

Do you have a thyroid condition?

Unknown

Never been checked

Normal

Hypothyroidism

Hyperthyroidism

Family history of thyroid issues?

Yes

No

If yes, please explain. (ex. mother / hypothyroid)

Primary Care Provider Name:

Primary Care Clinic or Hospital:

Date of last physical exam, if known:

MM slash DD slash YYYY

If date of physical exam is unknown, please estimate a time frame:

Within the past month

Within the past six months

Over a year ago

Over 5 years ago

Previous Surgeries (type and dates):

Do you have Allergies (seasonal, latex):

Yes

No

Please list your Allergies and the reaction you experience:

Are you currently disabled?

Yes

No

Please tell us more about your disablity:

Head/Brain injuries, seizure, stroke, concussion or loss of consciousness?

Yes

No

If yes, please explain:

Do you have pain which interferes with daily activities?

Yes

No

If yes, please list:

Do you exercise?

Yes

No

Please tell us more about your current exercise routine:

Have you gained / loss more than 10lbs in the past 6 months without trying?

Yes

No

If yes, how much weight gain/loss and reason if known:

Do you eat regular meals?

Yes

No

Describe a daily meal schedule:

Significant medical problems of immediate family members and/or medical problems that run on your side of extended family?

Do you have a health care directive?

Yes

No

Dental

Who is your current dental provider, if known?

When was your last dental visit?

Medication:

Preferred Pharmacy:

Please list your current medications (include the name and dose, if known):

Do you have any Medication Allergies?

Yes

No

If yes, please list your Medication Allergies:

Have you experienced any medication side effects:

Yes

No

If yes, please list the medication and the side effect you experienced:

Are you currently utilizing any Supplemental Medicinal Treatment (St. Johns wort, herbs, vitamins):

Yes

No

Please list any types of medicinal treatment used (St. Johns wort, herbs, vitamins):

Women:

Are you currently pregnant?

Yes

No

Due Date:

MM slash DD slash YYYY

Do you experience regular periods?

Yes

No

If no, please explain:

Additional Information:

Please list, to the best of your knowledge, any family members that currently work for Northland Counseling Center, Inc. to avoid a conflict of interest for your provider:

Please list, to the best of your knowledge, any people with whom you have had a signficant relationship with that currently or previously recieved services at Northland Counseling Center, Inc. to avoid a conflict of interest for your provider.

Person who is filling out this form

First Last

By checking this box you are acknowledging that all information presented is true to the best of your knowledge. Please sign the bottom of the form before submitting, Thank You - Northland Counseling Intake Staff!

I agree that all information is true and correct

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Friday: 8:00am to 12:00pm

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Northland Counseling Center, Inc.
Grand Rapids
Hibbing
International Falls
Kiesler Wellness Center
Aitkin

Northland Recovery Center, Inc.
Grand Rapids, MN
International Falls, MN

Copyright © 2022 Northland Counseling Center.
All Rights Reserved.

Northland Counseling Center Inc. does not discriminate in the provision of services to individuals based on their inability to pay, race, color, sex, national origin, disability, religion, or sexual orientation. It is the policy of Northland Counseling Center to provide essential medical services regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Northland Counseling Center Inc. accepts Medicare, Medicaid, private and CHIP. We will work with you to determine insurance eligibility.