Intake Form

Name
Client's legal name:   First Name   Last Name
Date:   Date
Preferred name:   First Name   Last Name
Gender:   F   M   Other   Gender
Pronouns:   Pronouns
Date of Birth:   Date   Age:   Number
Form Completed by (if someone other than client):
Address: Street Address   Address Line 2   City   State   Zip
Phone (home):   Area Code   Phone Number
Phone (work):   Area Code   Phone Number     Ext
Emergency Contact Name:   First Name   Last Name
Emergency Contact Phone:   Area Code   Phone Number
Therapist you’re scheduled with *

First Name Last Name
Primary reason(s) for seeking services:
Other mental health concerns (specify):
Counseling/ Prior Treatment History
Information about client (past & present):
Counseling/ Psychiatric Treament

Yes No
When
Where
Your reaction to overall experience
Suicidal thoughts/ attemps

Yes No
When
Where
Your reaction to overall experience
Drug/ alcohol treatment

Yes No
When
Where
Your reaction to overall experience
Hospitalizations

Yes No
When
Where
Your reaction to overall experience
Involvement with self-help groups (ex. AA. Al-Anon, NA, Overeaters Anonymous)

Yes No
When
Where
Your reaction to overall experience
Information about family/ significant others (past and present):
Counseling/ Psychiatric treatment

Yes No
When
Where
Your reaction to overall experience
Suicidal thoughts/ attempts

Yes No
When
Where
Your reaction to overall experience
Drug/ alcohol treatment

Yes No
When
Where
Your reaction to overall experience
Hospitalizations

Yes No
When
Where
Your reaction to overall experience
Involvement with self-help groups (ex. AA, Al-Anon, NA, Overeaters Anonymous)

Yes No
When
Where
Your reaction to overall experience
Please check behaviors & symptoms that occur to your more often than you would like them to take place:
Other (specify)
Briefly discuss how the above symptoms impair your ability to function effectively:
Any additional information that would assist us in understanding your concerns or problems:
What are your goals for therapy?
Do you feel suicidal at this time?

Yes No
If Yes, explain:
Chemical Use History
List of chemicals

Alcohol
Alcohol
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Barbiturates
Barbiturates
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Valium/ Librium
Valium/ Librium
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Cocaine/ Crack
Cocaine/ Crack
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Heroin/ Opiates
Heroin/ Opiates
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Marijuana
Marijuana
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

PCP/ LSD/ Mescaline
PCP/ LSD/ Mescaline
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Inhalants
Inhalants
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Caffeine
Caffeine
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Nicotine
Nicotine
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Over the counter
Over the counter
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Prescription drugs
Prescription drugs
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

Other drugs
Other drugs
Method of use & amount
Frequency of use
Age of first use
Age of last use
Used in last 48 hours

Yes No
Used in last 30 days

Yes No

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When and where you typically use substance:
Describe any changes in your use pattern:
Describe how your use has affected your family or friends (include their perceptions of your use):
Reason(s) for use:
Other (specify):
How do you believe your substance use affects your life?
Who or what has helped you in stopping or limiting your use?
Does someone in your family have a problem with drugs or alcohol (past or present)?
Have you had withdrawal symptoms when trying to stop using drugs or alcohol?

Yes No
If Yes, describe:
Have you had adverse reactions or overdose to drugs or alcohol? (describe):
Does your body temperature change when you drink?

Yes No
If Yes, describe:
Have drugs or alcohol created a problem for your job?

Yes No
If Yes, describe:
Family Information

Mother
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Father
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Spouse
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Child
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Child 2
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Child 3
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Child 4
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Other Parent/ caretaker
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

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Add additional Significant others (ex. Brothers, sisters, grandparents, step-relatives). Please specify relationships.

Significant other 1
Relationship
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Significant other 2
Relationship
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Significant other 3
Relationship
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Significant other 4
Relationship
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Significant other 5
Relationship
Name

First Name Last Name
Age
Living

Yes No
Living with you

Yes No

Charge 1
Charges
Date

Month Day Year
Date
Where (city)
Results

Charge 2
Charges
Date

Month Day Year
Date
Where (city)
Results

Charge 3
Charges
Date

Month Day Year
Date
Where (city)
Results

Charge 4
Charges
Date

Month Day Year
Date
Where (city)
Results

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Education
Years of Education
Currently enrolled in school?

Yes No
Fill in all that apply:

High school grad/ GED Vocational College Graduate Other training

Vocational Info
Vocational Info
Number of years:
Graduated?

Yes No
Majors

College Info
College Info
Number of years:
Graduated?

Yes No
Majors

Graduate Info
Graduate Info
Number of years:
Graduated?

Yes No
Majors

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Other training:
Special circumstances (ex. Learning disabilities, gifted):
Employment
List job history (begin with most recent job):

Employer 1
Employer
Dates
Title
Reason left
How often miss work?

Employer 2
Employer
Dates
Title
Reason left
How often miss work?

Employer 3
Employer
Dates
Title
Reason left
How often miss work?

Employer 4
Employer
Dates
Title
Reason left
How often miss work?

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Currently:
Other (describe):
Military
Military experience?

Yes No
Combat experience?

Yes No
Where:
Branch:
Date drafted:
Date enlisted:
Discharge date:
Type of discharge:
Rank of discharge date:
Leisure / Recreational
Describe special areas of interest or hobbies (ex. Art, reading, crafts, physical fitness, sports, outdoor activities, church activities, walking, diet/health, hunting, fishing, bowling, traveling, etc.):

Activity 1
Activity
How often now?
How often in the past?

Activity 2
Activity
How often now?
How often in the past?

Activity 3
Activity
How often now?
How often in the past?

Activity 4
Activity
How often now?
How often in the past?

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Medical / Physical Health
Other (describe):
List any health concerns:
List any recent health or physical changes:
List current prescribed medications

Prescribed Medication 1
Current prescribed medication
Dose
Dates
Purpose
Side Effects

Prescribed Medication 2
Current prescribed medication
Dose
Dates
Purpose
Side Effects

Prescribed Medication 3
Current prescribed medication
Dose
Dates
Purpose
Side Effects

Prescribed Medication 4
Current prescribed medication
Dose
Dates
Purpose
Side Effects

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list current over-the-counter medications

Over-the-counter medication 1
Current over-the-counter medication
Dose
Dates
Purpose
Side Effects

Over-the-counter medication 2
Current over-the-counter medication
Dose
Dates
Purpose
Side Effects

Over-the-counter medication 3
Current over-the-counter medication
Dose
Dates
Purpose
Side Effects

Over-the-counter medication 4
Current over-the-counter medication
Dose
Dates
Purpose
Side Effects

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Are you allergic to any medications or drugs?

Yes No
If Yes, describe:
Most Recent Examinations

Last physical exam
Date

Month Day Year
Date
Reason
Result

Last doctor's visit
Date

Month Day Year
Date
Reason
Result

Last vision exam
Date

Month Day Year
Date
Reason
Result

Last hearing exam
Date

Month Day Year
Date
Reason
Result

Most recent surgery
Date

Month Day Year
Date
Reason
Result

Upcoming surgery
Date

Month Day Year
Date
Reason
Result

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Family history of medical problems:
Please check if there have been any recent changes in the following:
Describe changes in areas in which you marked above:
For Staff Use
Therapist's signature / credentials:

Clear
Date

Month Day Year
Date
Should be Empty: