Crises Counselling Intake Form Section 1: Personal Information Full Name Date Of Birth MaleFemale Phone Number Email Emergency Phone Number Current Location (if different from home address) Section 2: Crises Situation Please describe the nature of the crisis or immediate concern that has led you to seek crisis counseling at this time. Are there any specific risk factors or safety concerns related to the crisis situation? How long have you been experiencing the current crisis or distressing situation? Section 3: Emotional State and Coping How would you describe your current emotional experiences related to the crisis (e.g., anxiety, fear, sadness)? What coping strategies have you used to manage your immediate distress and anxiety? Are there any physical symptoms or changes in your behavior that you have noticed since the crisis began? Section 4: Support System Who are your primary sources of support during this crisis? Are there any specific ways in which your support system has been helpful or challenging for you during this time? Section 5: Immediate Needs and Goals What are your immediate needs and goals for crisis counseling? What do you hope to achieve through this process? Are there any specific actions or steps that you believe would help address the crisis situation? Section 6: Additional Information Are there any other factors or information that you believe would be important for the counselor to know before beginning crisis counseling? Section 7: Consent and Agreement I understand that the information provided will be kept confidential within the limits of the law and professional ethics. I agree to participate in crisis counseling and understand that I have the right to ask questions and make choices about my counseling process.
