CLIENT INTAKE APPLICATION

Identification Information

Address

Street Address

City

State

Country

Postal code

Give a one-word description of your life now:

Criminal Justice

Charges Pending

Next hearing date

Address of PO

Terms of Probation/Parole

Prior Criminal History:

Date | City | Charges | Disposition

Have you ever been required to register as a sex offender?

Attorney/Public Defender's Name

Attorney/Public Defender's Address

Family History

Are you in contact with your family?

Father's Number

Describe your relationship with your parents in one phrase

How often are you in contact with them?

Was there violence in your growing up?

Were you ever abused as a child:

Physically

Emotionally

Sex

Marital History (including common law relationship)

What is your spouse's name

Spouse Address

Name of current/previous Spouse(s) [including common law] | Length of Marriage | No. of Children | Common Law

Have you ever been separated?

What were some of the issues in marriage?

Have you ever abused your spouse

Physically

Emotionally

Educational History

What was the last grade you completed?

Grade

College

Other

Do you have any plans to continue your education?

If yes, explain:

What are your vocational skills?

Employment History

What is your most recent employment status?

List your 5 most recent jobs:

Employer | Position | Started/Ended | Reason for Leaving

What kind of work experience do you have?

What kind of work are you interested in?

Previous Counseling History

Are you currently receiving help from another professional?

Who?

Have you or anyone in your family ever been diagnosed mentally ill?

Have you ever been Baker Acted?