Client Intake Form

Name

First NameLast Name

Date

Please take your time in providing the following information. The questions are designed to help me begin to understand you so that our time together can be as productive as possible. All information provided is confidential.

Referred by

Have you previously received any type of mental health services?

If yes, which of the following

Name of provider or facility

Location

Dates of treatment

Date

Reason for treatment

Briefly, what brings you in today?

When did your problem first start? Within the last

What areas of your life have been affected because of this problem?

Are you currently experiencing overwhelming sadness, grief or depression?

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks or have any phobias?

If yes, when did you begin experiencing this?

Please describe any major losses or traumas you have experienced:

What significant life changes or stressful events have you experienced recently?

What would you like to accomplish out of your time in therapy?

Where were you born?

Where did you grow up?

Please list your parents and siblings.

Who did you live with while growing up?

Mother's occupation

Father's occupation?

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 (father, grandmother, uncle, etc.).

Marital Status:

Please provide your partner's name and year deceased:

If married, how long have you been married for and what is your partners name

On a scale of 1 10 (best), how would you rate your relationship?

Are you currently in a romantic relationship?

How long?

On a scale of 1-10 (best), how would you rate your relationship?

Please list any children, their names, and ages:

Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for off-label use. Continue on the back if needed, or provide a separate list. If you have a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your health.

Prescribing provider and contact information:

Name

Specialty

Facility

Phone, email, or Fax

Format: (000) 000-0000.

How would you rate your current physical health?

Please list any specific health problems you are currently experiencing

How would you rate your current sleeping habits?

If you are having problems, in which phase of sleep are you experiencing issues?

How many times per week do you generally exercise?blanks What types of exercise do you participate in?

Are you currently experiencing any chronic pain?

If yes, please describe

Please describe current use of alcohol, cigarettes, and/or recreational drugs

Please describe previous use of alcohol, cigarettes, and/or recreational drugs

What do you enjoy about your work (full time homemaker included)? If retired, what did you enjoy about your

What do you find particularly stressful about your current or previous work?

What do you enjoy doing in your free time? What do you do to relax?

Do you consider yourself to be spiritual or religious? If yes, please 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?

CLIENT INTAKE FORM

Family History

Physical Health

Additional Information