Client Intake Form

CLIENT INTAKE FORM
Name

First NameLast Name
Date

MonthDayYear
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

Medical Provider:Insurance Provider:My WebsitePsychologyTodayFriend/Family:Other
Have you previously received any type of mental health services?

YesNo
If yes, which of the following

PsychotherapyMedicationOutpatient HospitalizationsInpatient Hospitalization
Name of provider or facility
Location
Dates of treatment

MonthDayYear
Date
Reason for treatment
Briefly, what brings you in today?
When did your problem first start? Within the last

30 days6-12 months2 yearsDuring adolescenceDuring childhood
What areas of your life have been affected because of this problem?
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?
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?
Family History
Where were you born?
Where did you grow up?
Where did you grow up?

CitySuburbsCountry
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:

Never MarriedDomestic PartnerMarriedSeparatedDivorced- for how long?Widowed: Please provide your partner's name and year deceased
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?

YesNo
How long?
On a scale of 1-10 (best), how would you rate your relationship?
Please list any children, their names, and ages:
Physical Health
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
How would you rate your current physical health?

PoorUnsatisfactorySatisfactoryGoodVery Good
Please list any specific health problems you are currently experiencing
How would you rate your current sleeping habits?

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

Falling asleepStaying asleepAwakening earlySleep apnea
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?

NoYes
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
Additional Information
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?
Should be Empty:

CLIENT INTAKE FORM

Family History

Physical Health

Additional Information