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
Today's Date: *

MonthDayYear
Date
Client's Name*

First NameLast Name
Parent/Legal Guardian (if under 18):*
Address*

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
Alternative phone#:

Area CodePhone Number
May we leave a message:

YesNo
Email:*
example@example.com
Alternative Email:
example@example.com
May we leave a message:

YesNo
*Please note: Email correspondence is not considered to be confidential medium of communication.
CLIENT DOB:*

MonthDayYear
Date
CLIENT Age: *
CLIENT Gender:*
CLIENT Marital Status:

Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed
Referred By (if any): *
Insurance Information

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

First NameLast Name
Client's Relationship to Insured:

SelfSpouseChildOther
Primary Insured Date of Birth:

MonthDayYear
Date
Insurance Company:

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

NoOther
Are you currently taking any prescription medication?*

YesNo
If yes, please list:
Have you ever been prescribed psychiatric medication?*

YesNo
If yes, please list and provide dates:
Have you ever been hospitalized for a psychiatric issue?*

YesNo
If yes, please explain and provide dates:
Have you ever had or are you currently experiencing thoughts of suicide?*
If yes, please explain and provide dates:
General and Mental Health Information
Explain in a few short sentences why you are seeking therapy services at this time?*
How would you rate your current physical health? (Please circle one)*

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

PoorUnsatisfactorySatisfactoryGoodVery 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?*

YesNo
If yes, for approximately how long?
Are you currently experiencing anxiety, panic attacks or have any phobias?*

YesNo
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain?*

YesNo
Do you drink alcohol more than once a week?*

YesNo
If yes, please describe:
How often do you engage in recreational drug use?*

DailyWeeklyMonthlyInfrequentlyNever
Are you currently in a romantic relationship?*

YesNo
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*

YesNo
List Family Member (if yes)
Anxiety*

YesNo
List Family Member (if yes)
Depression*

YesNo
List Family Member (if yes)
Domestic Violence*

YesNo
List Family Member (if yes)
Eating Disorders*

YesNo
List Family Member (if yes)
Obesity*

YesNo
List Family Member (if yes)
Obsessive Compulsive Behavior*

YesNo
List Family Member (if yes)
Schizophrenia*

YesNo
List Family Member (if yes)
Suicide Attempts*

YesNo
List Family Member (if yes)
Additional Information
Are you currently employed?*

YesNo
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?

NoYes
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 during 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