Adult Intake Form | Colorado Visiting Nurse Association

Name

First Last

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Mobile Phone

Is it OK to leave a message?

Yes
No

Is it OK to use texting for appointment scheduling/confirmations?

Yes
No

Email*

Date of Birth

Age

Emergency Contact

First Last

Relationship

Phone

Information about the Deceased

Name of Deceased

First Last

Relationship to Deceased

Date of Death

Age at Death

Place of Death

Cause of Death

Was the person who died a hospice patient?

Yes
No

If yes, please give the name of the hospice.

Have you experienced any other losses in the past year?

Personal Information/Life Situation

Marital Status:

Household Members/Significant Others

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Are you currently working?

Yes
No

What kind of work do you do?

Please list any mental health concerns/diagnosis:

Are you currently receiving counseling services from another provider?

Yes
No

Therapist Name

Therapist Phone

Have you seriously considered or attempted suicide?

Yes
No

Please explain:

Have you been hospitalized for physical/mental health reasons within the last 5 years?

Yes
No

Please explain:

Please list any current medical conditions:

Please list any current medications you are taking:

Have you ever abused drugs or alcohol?

Yes
No

Please explain:

People who are grieving may experience any of the following symptoms. Do any of these apply to you?

On a scale of 1-5, please check the number that best describes your experience at this moment.

Not True True

I understand how grief is affecting me.

I have tools to cope with my grief effectively.

I can handle the intense feelings that go with grief (i.e. guilt, anger, fear, sadness).

I can handle the intense feelings that go with grief.

I know what kind of support I need in my grief and where to find it.

I believe that I can go on living and loving even though my loved one is gone.

Please list any support resources available to you at this time (i.e. friends, family, church, community groups,activities).

What prompted you to seek grief counseling and what are you hoping to get out of your sessions?

Anything else you would like your counselor to know about you?

Where did you hear about CVNA Grief Counseling Services?

Preferences

Please know that we will do our best to accommodate but cannot guarantee availability.

Location:

Home
Counseling Office
Phone/Video Counseling

Day of week (mark all that apply):

Monday
Tuesday
Wednesday
Thursday
Friday

Time of day (mark all that apply):

Morning
Afternoon
Evening

Consent

I consent to allow Colorado VNA to collect the information on this form.

*Information included on this form is protected by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and will remain confidential between the applicant and group facilitators and will not be shared with the group without specific permission.

Email

This field is for validation purposes and should be left unchanged.