POSS Psychotherapy Client Intake Questionnaire

Psychotherapy Client Intake Questionnaire

Please fill in the information below and bring it with you to your first session. Please note: information provided on this form is protected as confidential information.
Personal Information
Name: *
Date: *

Month Day Year
Date
Parent/Legal Guardian (if under 18): *
Address: *
Cell/Home/Work/Other Phone: *
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: *
Age: *
Gender: *
Marital Status:

Never Married Domestic Partnership Married Separated Divorced Widowed
Referred By (if any):
History
Have you previously received any type of mental health services psychotherapy, psychiatric services, etc? *

No Yes, previous therapist/practitioner:
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?

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

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

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

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

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

No Yes
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?

No Yes
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? *
Should be Empty:

Psychotherapy Client Intake Questionnaire

Personal Information

History

General and Mental Health Information

Family Mental Health History

Additional Information