Client Intake Form - Marianna Serenity Centre

MARIANNA SERENITY CENTER

Intake Form

Thank you for choosing Marianna Serenity Center (MSC). This form helps us understand your current concerns, relevant personal history, well-being needs, and the type of support that may be appropriate for you.

Please answer the questions as honestly as you feel comfortable. You do not have to provide information that is not relevant to your care or that you are not ready to disclose.

Advancing Soul Wellness, Strengthening Systems, Sustaining Impact.

Client Intake Form

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1. CLIENT INFORMATION

Here are the main details about our client.

Full Name

Preferred Name

Date of Birth

Age

Gender

Phone/Mobile

Client Address

Country

State

Occupation/Profession

Organisation/Institution

Marital/Relationship Status

2. WHAT BRINGS YOU TO COUNSELLING?

Client Details about the counseling program.

What has brought you to counselling at this time?

What would you say is your main concern at the moment?

When did this concern begin?

How is this concern currently affecting your life

YOUR COUNSELLING GOALS

3. YOUR COUNSELLING GOALS

What would you like counselling to help you with?

What changes would you most like to see in yourself or your situation?

What would make you feel that counselling has been helpful to you?

4. EMOTIONAL & PSYCHOLOGICAL WELLBEING

Other Details about the counselling program.

Over the past few weeks, have you experienced any of the following?

	Never	Sometimes	Often	Very Often
Feeling overwhelmed
Persistent worry
Sadness or low mood
Irritability or anger
Difficulty concentrating
Difficulty sleeping
Low motivation
Emotional exhaustion
Loneliness/isolation
Difficulty regulating emotions
Loss of interest in usual activities
Feeling unable to cope

Is there anything about your emotional or psychological wellbeing that you would like your counsellor to know?

5. PREVIOUS COUNSELLING OR PSYCHOLOGICAL SUPPORT

Past counselling experience

Have you previously received counselling, psychotherapy or psychological support?

when?

What was the main reason for seeking support?

Was the support helpful?

Are you currently receiving counselling, psychotherapy or psychological treatment elsewhere?

Please provide any information you believe is relevant:

6. MEDICAL & HEALTH HISTORY

Existing health history.

Do you currently have, or have you previously had, any significant medical condition that may be relevant to your wellbeing?

Please provide details:

Are you currently taking any prescribed medication?

Please state the medication and, if known, its purpose:

Have you ever been hospitalised for a physical or psychological health concern?

Please provide relevant details:

Is there any other health information you believe your counsellor should know?

7. PSYCHOLOGICAL & PSYCHIATRIC HISTORY

Medical Mental History

Have you ever received a psychological or psychiatric diagnosis?

Please provide the diagnosis if you know it:

Have you ever received psychiatric treatment?

Have you ever been admitted to a psychiatric facility or received inpatient mental-health care?

Please provide any relevant information you are comfortable sharing:

Are you currently under the care of a psychiatrist, psychologist, doctor or other mental-health professional?

Please state the Service/Professional

Please provide the contact information, if relevant and if you consent to providing it.

8. REHABILITATION & SUBSTANCE-USE HISTORY

Have you ever attended a rehabilitation, recovery or substance-use treatment programme or centre?

Please provide Approximate date/period

Please provide Reason for attending

Was the programme completed?

Are you currently receiving support for substance use or recovery?

Do you currently use alcohol, prescription medication or other substances in a way that concerns you or affects your wellbeing?

If you wish to provide further information:

9: FAMILY & RELATIONSHIP BACKGROUND

Family & Relationship

Are there current family or relationship circumstances affecting your wellbeing?

Please describe:

Which areas would you like support with?

Is there anything about your family history that you believe is relevant to your current concern?

10: SIGNIFICANT LIFE EXPERIENCES

Other Life experiences

Have you experienced any significant event or circumstance that continues to affect you?

If you wish, please provide further information

11: CURRENT SUPPORT SYSTEM

Support system

Who do you currently rely on for emotional or practical support?

Is there someone you trust who could be contacted in an emergency if necessary?

Please provide us your Name

Please provide us your Relationship status with them

Please provide us your Phone Number

Please provide us your Email (optional)

12: SAFETY & IMMEDIATE SUPPORT

These questions are asked for your safety and to help us determine the most appropriate level of care.

Have you recently felt that you do not want to live or that life is not worth living?

Have you recently had thoughts of harming yourself?

Have you ever attempted to seriously harm yourself or end your life?

Have you recently had thoughts of seriously harming another person?

Do you currently feel unsafe because of another person, your home environment, a relationship, workplace or another situation?

Is there anything happening currently that you believe requires urgent professional assistance?

13: SPIRITUAL / FAITH CONSIDERATIONS

This section is optional.

Would you like your faith or spirituality to be considered as part of your counselling process?

Are there spiritual, religious or faith-related concerns that are relevant to what you are experiencing?

14: PERSONAL STRENGTHS & COPING

What do you believe are your greatest personal strengths?

What has helped you cope with difficult situations in the past?

What currently gives you hope, motivation or a reason to keep moving forward?

What would you like your counsellor to understand about you that may not be captured by the questions above?

15: REFERRAL & ACCESS INFORMATION

How did you get here with us?

How did you hear about Marianna Serenity Center?

Were you referred specifically for counselling by another professional or organisation?

Do you consent to MSC communicating with the referring professional/organisation where necessary for your care?

16: CLIENT DECLARATION & CONSENT

I understand that this form is intended to assist with my counselling intake and initial understanding of my needs. I understand that completing this form does not automatically establish a diagnosis or guarantee that counselling at MSC will be the appropriate service for me.

I understand that my information will be handled confidentially and in accordance with applicable professional, ethical and data-protection requirements, subject to the limits of confidentiality stated above.

I understand that MSC may recommend referral to another appropriately qualified professional or service where my needs fall outside the scope of the counselling service or where another form of care would be more appropriate.

I confirm that the information I have provided is accurate to the best of my knowledge.

Yes

Client Name

Date

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17: FOR CLIENTS UNDER 18

Parent/Guardian Name

Relationship to Client

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