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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
Gender *
Select the term(s) with which you most identify
Marital Status *
May we leave a message?
May we leave a message?
May we email you? *
Occupational Information
Are you currently employed? *
Are you happy in your current position
Does your work make you stressed?
Religious/Spiritual information
Are you currently receiving Psychological Services, professional counseling, Psychiatric Services, or any other Mental Health Services? *
Have you had any Mental Health Services in the past *
Are you currently taking any psychiatric prescription medications? *
Have you ever been prescribed of psychiatric prescription medication *
How is your physical health at the present time? *
enter none if appropriate
Do you take medication for physical / medical issues? *
Are you having any problems with your sleep habits? *
How many times a week do you exercise?
Are there any changes or difficulties with your eating habits? *
If yes:
Have you experienced any unplanned weight change in the last 2 months? *
Do you consume alcohol regularly?
How often do you engage in recreational drug use? *
Have you felt depressed recently?
Have you had any suicidal thoughts recently? *
If yes:
if yes, how often?
Are you currently in a romantic relationship? *
Check the box of symptoms you may be experiencing now relating to your Issue .