Client Intake Form

Name:

Date:

Address:

Date of Birth:

Address:

City: State: Zip:

E-Mail:

SSN:

Phone:

Alt - Phone:

Race:

Sex:

Age:

Please enter a number from 1 to 120.

Marital Status:

Whom may we thank for your referral?

Table of Contents

PEOPLE THAT WILL ALWAYS KNOW HOW TO CONTACT YOU:

Name of Closest Relative:

Phone

Relationship:

Address:

Name:

Phone

Address:

Relationship:

Name:

Phone

Address:

Relationship:

EDUCATION

Highest Grade Completed:

College:

Vocational School:

EMPLOYMENT AND MILITARY HISTORY

Present Employer:

How Long:

Address:

Job Description:

Salary:

Supervisor:

Phone

May we call you at work?

Prior Employers:

Military History:

MEDICAL HISTORY

Have you ever been diagnosed or treated for any alcohol or drug addiction issues? If so where were you treated and what were you treated for?

Have you had any psychiatric examinations before this incident?

Have you had any chronic health problems? If so, list them below:

Did you use any medication regularly before this incident? If so, list the type and the reason:

CIRCUMSTANCES OF ARREST

Describe (Date, Time and Place, etc…)

Description (Continued)

Witness Name(s) and address, if known:

OTHER PERSON(S) ARRESTED:

Name:

Attorney (if known):

Name:

Attorney (if known):

Name:

Attorney (if known):

PROBATION OR PAROLE STATUS

Are you on probation or parole?

If yes, Probation Officer:

County:

Charges:

Suspended Sentence:

PRIOR CRIMINAL RECORD (INCLUDING JUVENILE RECORD)

County + Charge:

Date:

Sentence:

County + Charge:

Date:

Sentence:

County + Charge:

Date:

Sentence:

Charge:

Date:

Sentence:

DISCLOSURE

Please list all persons authorized to receive information pertaining to your case, write “none” if none:

Name:

Phone:

Name:

Phone:

Address

Address:

Relationship:

Address

Address:

Relationship:

Client Intake Form

PEOPLE THAT WILL ALWAYS KNOW HOW TO CONTACT YOU:

EDUCATION

EMPLOYMENT AND MILITARY HISTORY

MEDICAL HISTORY

CIRCUMSTANCES OF ARREST

OTHER PERSON(S) ARRESTED:

PROBATION OR PAROLE STATUS

PRIOR CRIMINAL RECORD (INCLUDING JUVENILE RECORD)

DISCLOSURE

ATTORNEY NOTES

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