New Client Intake Today's Date Referral Source CLIENT CONTACT NAME CELL PHONE ALTERNATE PHONE EMAIL ADDRESS WOULD YOU LIKE TO RECEIVE EMAILS FOR FREE PORCHLIGHT EVENTS? IMPORTANT NOTE ABOUT SERVICES: Porchlight Counseling offers 20 free sessions to students who have survived sexual assault while enrolled at a college or university. If you are seeking counseling for sexual assault that occurred while you were underage, or after you graduated, you will not be eligible for the Porchlight Counseling program. If you are not eligible, please contact email@example.com for referral information. CLIENT SUMMARY (Please describe the situation you are seeking counseling services for and write down personal goals that you hope to achieve through counseling.) CLIENT INFORMATION DATE OF BIRTH MARRIED/SINGLE? CHILDREN? IDENTIFIED GENDER IDENTIFIED ETHNICITY EMPLOYED? PT/FT? ANNUAL INCOME IF EMPLOYED INSURANCE? (Porchlight does not accept insurance, but passes this information to the assigned therapist to inform students of their options when completing their 20 visits) AVAILABILITYBe as specific as possible. Include times that you are available.Example: 8am – 10am instead of writing morning. Monday: Tuesday: Wednesday: Thursday: Friday: Saturday (limited therapist availability): TRANSPORTATION Do you have a car, or do you rely on public transportation? UNIVERSITY YEAR Freshman, sophomore, junior, or senior PROGRAM OF STUDY LIVING SITUATION Dorm, Apt, Roommates SUPPORT NETWORK Family and friends that you confide in and who support you. If you have not confided in anyone, please state that here. SUBSTANCE USE? Do you drink alcohol or use drugs for recreational purposes? If so, how often? If you use drugs, please state what kind. FAMILY HISTORY OF SUBSTANCE USE? FAMILY HISTORY OF MENTAL ILLNESS? HISTORY WHEN DID THE ASSAULT TAKE PLACE? WAS IT A SINGLE ASSAULT, OR DID IT OCCUR MULTIPLE TIMES OVER A SPAN OF TIME? HAVE YOU EXPERIENCED A DOMESTIC VIOLENCE SITUATION OR OTHER TRAUMA BEFORE OR AFTER THE ASSAULT? DID YOU REPORT THE ASSAULT(S)TO: POLICE, SCHOOL, FAMILY/FRIENDS? DID YOU SEEK MEDICAL CARE FOR THE ASSAULT(S)? WHAT DO YOU PERCEIVE TO BE THE CURRENT PROBLEM, INCLUDING SYMPTOMS AND THEIR IMPACT ON YOUR EVERYDAY LIFE? WHY ARE YOU SEEKING SERVICES NOW? TRIGGERS? MOTIVATION? ANY KNOWN MEDICAL CONCERNS BEFORE THE ASSAULT TOOK PLACE? CURRENTMEDICATIONS? NAME? DOSAGE? FREQUENCY? COMPLIANCE AND NAME OF PHYSICIAN PRESCRIBING? ANY PREVIOUS HOSPITALIZATION RELATED TO THE ASSAULT? ANY HOSPITALIZATION RELATED TO MENTAL HEALTH CONCERNS? PLEASE LIST THE REASON FOR HOSPITALIZATION AND THE DURATION CURRENT COUNSELING HISTORY? WHEN DID YOU RECEIVE COUNSELING? DURATION? TREATMENT PLAN? REASON FOR TERMINATION? DO YOU CURRENTLY EXPERIENCE SUICIDAL THOUGHTS? HAVE YOU RECENTLY SELF HARMED OR ATTEMPTED SUICIDE? HAVE YOU SELF HARMED OR ATTEMPTED SUICIDE IN THE PAST?