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Client Intake Form
Please answer the following questions to the best of your ability. These questions are intended to help the therapist with the therapy process. All information is completely confidential.
Personal Information
First Name
*
Middle Initial
Last Name
*
Email Address
*
Birthdate
*
Gender
*
Male
more
Female
Select the term(s) with which you most identify
Agender
Cisgender (non-trans) Man
Cisgender (non-trans) Woman
Gender Non-conforming
Gender Variant
Genderqueer
Intersex
Non-binary
Not Listed
Transgender Man
Transgender Woman
Marital Status
*
Never married
Partnered
Married
Separated
Divorced
Widowed
Number of children
Child(ren)'s Ages
Who is in your support system? Friends, family, work, etc..
Current address
*
Home Phone
May we leave a message?
Yes
No
Cell/other Phone
May we leave a message?
Yes
No
Email Address
May we email you?
*
Yes
No
List current members of family and others living in home include name age and relationship
*
Brief family history (parents, siblings, childhood )
Occupational Information
Are you currently employed?
*
Yes
No
IWhat is your occupation?
What is your position?
Are you happy in your current position
Yes
No
Does your work make you stressed?
Yes
No
What are your work-related stressors?
Religious/Spiritual information
Spiritual Beliefs
Referred by:
Are you currently receiving Psychological Services, professional counseling, Psychiatric Services, or any other Mental Health Services?
*
Yes
No
If yes, what is the reason for the change?
Have you had any Mental Health Services in the past
*
Yes
No
Are you currently taking any psychiatric prescription medications?
*
Yes
No
If yes, please list:
Have you ever been prescribed of psychiatric prescription medication
*
Yes
No
If yes, please list:
How is your physical health at the present time?
*
Poor
Unsatisfactory
Satisfactory
Good
Very good
Please list any persistent physical symptoms or health concerns (e.g. Chronic pain, headaches, hypertension, diabetes, thyroid dysfunction, Etc. ):
*
enter none if appropriate
Do you take medication for physical / medical issues?
*
Yes
No
If yes, please list:
Are you having any problems with your sleep habits?
*
Yes
No
please describe:
How many times a week do you exercise?
Days
*
Minutes/Hours
*
Are there any changes or difficulties with your eating habits?
*
Yes
No
If yes:
eating less
eating more
binging
restricting
Have you experienced any unplanned weight change in the last 2 months?
*
Yes
No
Do you consume alcohol regularly?
Yes
No
In one month, how many times do you have four or more drinks in a 24-hour period?
Do you have any current legal issues? If so please describe.
*
How often do you engage in recreational drug use?
*
Daily
Weekly
Monthly
rarely
never
Have you felt depressed recently?
Yes
No
If so, for how long?
Have you had any suicidal thoughts recently?
*
Yes
No
If yes:
frequently
sometimes
rarely
if yes, how often?
frequently
sometimes
rarely
If yes, how long ago?
Are you currently in a romantic relationship?
*
Yes
No
If yes, how long have you been in this relationship?
On a scale from 1 to 10 how would you rate the quality of your relationship? (10 being great)
In the last year, have you had any major life changes (e. g. New job, new home, illness, relationship change, Etc. )?
*
Check the box of symptoms you may be experiencing now relating to your Issue .
changes in sleep habits
changes in eating habits
anger outbursts
difficulty concentrating
weight gain or loss
extreme restlessness
emotional variances
Suicidal Thoughts
homicidal thoughts
extreme bursts of energy
apathy
overwhelming guilt / shame
poor impulse control
anxiousness
any other notable symptoms
periods of hopelessness or helplessness
What are your goals for your therapy?
Is there anything else you would like the therapist to know?
*
Signature
*
Date
*
Submit
