CONFIDENTIAL CLIENT INTAKE

CONFIDENTIAL CLIENT INTAKE
Mehri Aboutalebi, Ph.D. License # MFT47272

Please fill in the information below to the best of your ability.

You may leave a field blank or write N/A if it is not applicable to you.

Please note: information provided on this form is protected as confidential information
Personal Information
Name

First NameLast Name
Date:

MonthDayYear
Date
Date of Birth:

MonthDayYear
Date
Place of Birth:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)

Area CodePhone Number
Phone Number (Cell)

Area CodePhone Number
Email:
example@example.com
May we text your cellphone / email you /or leave a voicemail for you?

YesNo
Person to notify in the event of an emergency:

First NameLast Name
Person's relationship to you:
Emergency Phone Number

Area CodePhone Number
Where did you hear about us? (Google, Yelp, Referral, etc)*
EDUCATION & VOCATIONAL INFORMATION
Highest Degree Obtained:
Current Occupation
Working Status:

Full TimePart TimeStudentNot Working / Other
Do you enjoy your work? Do you find anything stressful about your current work?
Spiritual /cultural History:
Do you identify with a particular religion, culture, or spiritual practice? If so, please describe:
Do any of the above religious, cultural, or spiritual issues contribute to your current concerns, problems, or issues? If so, please describe:
What was your religious & cultural upbringing?
Relationship Status
Present Relationship Status (check all that apply):

SingleMarried/PartneredIn a new relationshipDatingWidow/WidowerDivorcedSeparatedOther
Please input the period of time you've been in your current relationship status:
Are you in an abusive relationship?

YesNoSomewhatUnsure
If married, partnered, or in a primary relationship - do you live with your partner?

YesNoNot Married / Partnered
Do you live with any children or step children?

YesNo
Please list the people who live in your household? (Name, Relationship to you, Age)
Have you married previously or been in a long term relationship? If yes please state when and for how long:
If you are married or in a relationship, rate your level of satisfaction with your relationship on a scale of 1 to 10 (with 10 being extremely happy.) Briefly explain why you chose your rating.
FAMILY INFORMATION
Were you raised by:

Both ParentsSingle ParentRelativeOther
Describe your parent(s) or caretaker with one word (for each):
How many siblings do you have?
If you have siblings please state your birth order from first to last (ex. sister, me, brother)
Have you immigrated?

YesNo
If yes, at what age?
General Mental and Medical Information
Doctors Name

First NameLast Name
Doctors Contact Information

Area CodePhone Number
How would you rate your physical health

ExcellentGoodFairPoor
Please list any specific health problems you are currently experiencing:
List any medications you are taking including non-prescription, herbal, or remedies:
List any history of significant physical problems (e.g, broken bones, head injury, surgery, shortness of breath, headaches, body aches):
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

YesNo
If yes, what was the providers name?
Have you been prescribed any psychiatric medication?

YesNo
If yes, please list and provide dates:
Psychiatrist's Name:
Psychiatrist's Phone Number:

Area CodePhone Number

In the section below, identify if there is a family history of any of the following.

Rows	Yes	No
Alcohol / Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts

If 'yes' to any of the above please list which and which family member(s) it affected or still affects.
Have you ever been hospitalized for a drug or alcohol problem?

YesNo
Have you ever struggled with either drugs or alcohol?

YesNo
If 'yes' to either when and where?
Do you smoke or drink? If so, how much and how often?
Current Stressors:
What significant life changes or stressful events have you experienced recently?
Are you experiencing any of the following?:

Legal IssuesFinancial IssuesFamily ProblemsFamily illnessMajor Life TransitionsRecent Losses or Changes(jobs, relationships, or anything else)
List any current or past legal issues:
Military History:
Have you served in the military?

YesNo
If 'yes' please state the duration and time period of your military service.
Mental Health/Risk
Please identify if you have experienced any of the following and whether this is a past, current, or reoccurring issue:
Please identify if you have experienced any of the following

Suicidal thoughtsThoughts of wanting to intentionally self harmThoughts of wanting to cause harm to others
If you indicated that you feel like self harming or harming others please identify how likely it is that you may act on these impulses:

Imminently LikelyNot likely at allN/A
If you have experienced any of the above please state if the thoughts were in the Past, are in the Present, or are Reoccurring thoughts:
How frequent are these thoughts (or have been in the past):
For how long have you had these thoughts?
Goals of Treatment
What compelled you to start therapy at this time?
Describe issues or problems that you hope to resolve:
What do you consider to be some of your weaknesses?
What do you consider to be some of your strengths?
What do you hope to gain from therapy?
Please let me know in the space provided, of anything that was not addressed in this intake, and anything that you would like me to know about you, your goals, your relationships, or any recent significant life events:
Patient Signature:*
Date:*

MonthDayYear
Date
Should be Empty:

CONFIDENTIAL CLIENT INTAKE

Personal Information

EDUCATION & VOCATIONAL INFORMATION

Spiritual /cultural History:

Relationship Status

FAMILY INFORMATION

General Mental and Medical Information

Current Stressors:

Military History:

Mental Health/Risk

Goals of Treatment