Counseling Intake Form | Wellness House of Annapolis

Please click the “Counseling Services PDF” button above and read important information about our counseling services before completing the Counseling Intake Form below.

By placing your signature on the completed Counseling Intake Form, located below, you are indicating that you have read and understand the above information and that any questions have been answered to your complete satisfaction. Your signature indicates that you agree with the conditions of counseling as stated therein.

Member Counseling Intake Form
Today's Date *
Name *

First

Last
Date of Birth *
Phone (Cell) *
Phone (Home)
Email Address *
Please Check One of the Following: *

#1. I am a cancer patient. #2. I am a caregiver/family member of a loved one with cancer. #3. I am grieving the loss of a loved one who had cancer.
Type of Cancer (If You Checked #1 or #2)

(Complete only if you checked #1 or #2.)
Stage of Cancer (If You Checked #1 or #2)
Date of Diagnosis (If You Checked #1 or #2)

(Complete only if you checked #1 or #2.)
Approximate Dates of Treatment (If You Checked #1 or #2)

(Complete only if you checked #1 or #2.)
Relationship to Person with Cancer (If You Checked #2 or #3)

(Complete only if you checked #2 or #3.)
My Support Network Includes: *

Myself Family Friends Community Other Select all that are applicable.
List Details of Your Support Network (Person's Name, Your Relationship, and How They Assist You)

(Include some details on people in your support network.)
Rate how you are coping with the diagnosis (1-Extremely Poor; 10-Extremely Well): *

On a scale from 1-10.
Rate your overall level of stress (1-Extremely Low; 10-Extremely High): *

On a scale from 1-10.
Rate your belief that sharing thoughts/concerns is helpful (1-Extremely Unhelpful; 10-Extremely Helpful): *

On a scale from 1-10.
Have you received counseling services in past or present? *

Yes No
Which of the following coping activities have been helpful to you? *

Exercise Spiritual Practices Connecting With Others Counseling Mindfulness Writing/Art/Music/Dance or Other Expressive Activities Spending Time Outdoors/Gardening Other (Please Explain Below) (Select All That Are Applicable)
*If you selected "Other" above, please list some details on the activities you engage in to help you cope with the diagnosis:
My Overall Concerns Are Related To: *

Work Finances Relationships Emotional Spiritual Other
Here is some space to share details about your concerns if you would like:

Give us an idea about what's been going on with you.
What do you hope to get from your counseling sessions? *

Give us an idea about what you would like to work on or discuss.
Personal Strengths / Goals *

Give us an idea about some of your personal strengths and goals.
What other Wellness House services have you been using? Have they been helpful?

Let us know what other services and activities you are engaged in at Wellness House.
Do you have any questions about counseling, support groups or other Wellness House services?

Ask any questions you may have regarding counseling, support groups or other services.
Please check to confirm that you have read and understand the information in the Counseling Services PDF (located above) and that any questions have been answered to your satisfaction. *

I confirm
Signature of Informed Consent

By your signature, you are indicating you have read and understand the information in the Counseling Services PDF (located above) and that any questions have been answered to your satisfaction. Your signature indicates that you agree with the conditions of counseling as stated therein.
Signature *
Date *

Member Counseling Intake Form

Signature of Informed Consent