POSS Psychotherapy Client Intake Questionnaire

Psychotherapy Client Intake Questionnaire

Please fill in the information below for all fields that apply. Please note: information provided on this form is protected as confidential information.
Personal Information
Client's Name *

First Name Last Name
Date: *

Month Day Year
Date
Parent/Legal Guardian (if under 18): *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell/Home/Work/ Other Phone: *

Area Code Phone Number
May we leave a message:

Yes No
Email: *
example@example.com
May we leave a message:

Yes No
*Please note: Email correspondence is not considered to be confidential medium of communication.
DOB: *

Month Day Year
Date
Age: *
Gender: *
Marital Status:

Never Married Domestic Partnership Married Separated Divorced Widowed
Referred By (if any): *
Insurance Information

Please check with us to gain the latest information on our network participation.
Primary Insured Name

First Name Last Name
Client's Relationship to Insured:

Self Spouse Child
Primary Insured Date of Birth:

Month Day Year
Date
Insurance Company:

Optum/United Health Horizon Blue Cross Blue Shield
Insurance ID#:
History
Have you previously received any type of mental health services psychotherapy, psychiatric services, etc? *

No
Are you currently taking any prescription medication? *

Yes No
If yes, please list:
Have you ever been prescribed psychiatric medication? *

Yes No
If yes, please list and provide dates:
Have you ever been hospitalized for a psychiatric issue? *

Yes No
If yes, please explain and provide dates:
General and Mental Health Information
How would you rate your current physical health? (Please circle one) *

Poor Unsatisfactory Satisfactory Good Very good
Please list any specific health problems you are currently experiencing:
How would you rate your current sleeping habits? (Please circle one) *

Poor Unsatisfactory Satisfactory Good Very good
Please list any specific sleep problems you are currently experiencing:
How many times per week do you generally exercise?
What types of exercise do you participate in?
Please list any difficulties you experience with your appetite or eating problems:
Are you currently experiencing overwhelming sadness, grief, or depression? *

Yes No
If yes, for approximately how long?
Are you currently experiencing anxiety, panic attacks or have any phobias? *

Yes No
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain? *

Yes No
If yes, please describe:
Do you drink alcohol more than once a week? *

Yes No
How often do you engage in recreational drug use? *

Daily Weekly Monthly Infrequently Never
Are you currently in a romantic relationship? *

Yes No
If yes, for how long?
On a scale of 1 -10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
What significant life changes or stressful events have you experiences recently?
Family Mental Health History
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)
Alcohol/Substance Abuse *

Yes No
List Family Member (if yes)
Anxiety *

Yes No
List Family Member (if yes)
Depression *

Yes No
List Family Member (if yes)
Domestic Violence *

Yes No
List Family Member (if yes)
Eating Disorders *

Yes No
List Family Member (if yes)
Obesity *

Yes No
List Family Member (if yes)
Obsessive Compulsive Behavior *

Yes No
List Family Member (if yes)
Schizophrenia *

Yes No
List Family Member (if yes)
Suicide Attempts *

Yes No
List Family Member (if yes)
Additional Information
Are you currently employed? *

Yes No
Do you enjoy your work? Is there anything stressful about your current work?
If yes, what is your current occupation and how long have you been doing it?
2. Do you consider yourself to be spiritual or religious?

No Yes
If yes, describe your faith or belief:
What do you consider to be some of your strengths? *
What do you consider to be some of your weaknesses? *
What would you like to accomplish out of your time in therapy? *
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Psychotherapy Client Intake Questionnaire

Personal Information

Insurance Information

History

General and Mental Health Information

Family Mental Health History

Additional Information