Client Intake Form

What is the name of your therapist (select all that apply)?*

Justin Gregory Briggs, Ph.D., LMFTHannah Allison, M.MFTKyisha Arnwine, M.MFTJessica Bare, M.MFTPaige Blackwell, LMFTKatie Etchart, M.MFTSeth Frank, M.MFTNatalie Hoyt, LMFTCailin Jaspers, M.A.Perry Lines, LMFTAnna Marks, M.MFTJeannie Milan, LMFTHannah Mills, LMFTKayli Norris, M.MFTTrent Perry, LPC-MHSPLauren Peterson, TLMFTJulianne Reed, M.MFTMatt Samek, LMFTRachel Simon, TLMFTKathleen "Kasey" Smith, M.MFTLandry Smith, TLMFT

Todays Date:

MonthDayYear

Personal Title:

Client First Name:

Client Middle Name:

Client Last Name:

Street Address:

City:

State:

Zip Code:

Parent/Guardian 1 (If applicable)

First NameLast Name

Email Address:

Primary Phone Number:

Secondary Phone Number:

Client Birthdate:

MonthDayYear

Biological Sex:

Gender Identity

Race/Ethnicity:

Sexual Orientation:

Relationship Status:

Current relationship length:

Religion & Spirituality

How important is your religion or spirituality to you?

1 is Not Important, 5 is Very Important

Highest Level of Education:

How did you hear about Dr. Briggs and The Briggs Institute, Inc.?

If you were referred by Lyra Health and you have a Lyra code, please provide it here:

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Phone Number

Please list the names and phone number/s of any additional emergency contacts

Please tell me the names, ages, and type of relationship you have (e.g., sister, brother, parent, friend) with the people who live with you.

Employer:

Position:

Dates Employed:

Annual Household Income

Have you been to therapy before?

YesNo

If you have been to therapy, please select one or more of the following to rate your experience/s.

Here is a general timeline of key developmental milestones from conception to age 18. Please note that individual variations may occur, and these milestones are not exhaustive:

Conception to Birth (Prenatal Development):

0-2 weeks: Fertilization, zygote formation, and implantation into the uterus.
3-8 weeks: Embryonic development, formation of major organs and body systems (e.g., heart, lungs, and limbs).
9-38 weeks: Fetal development, growth, and maturation of organs and systems (e.g., brain development, increasing size).

Infancy (0-2 years):

0-3 months: Reflexes (e.g., grasping, stepping), visual tracking (following a moving object), and social smiling (smiling in response to caregiver).
4-6 months: Rolling over (moving from back to stomach), sitting with support, reaching for objects (e.g., toys), and babbling (repeating consonant-vowel sounds).
7-9 months: Sitting without support, crawling, understanding simple words (e.g., "no"), and developing stranger anxiety (distress around unfamiliar people).
10-12 months: Pulling up to stand, cruising (walking while holding onto furniture), first words (e.g., "mama," "dada"), and recognizing familiar faces.
12-18 months: Walking independently, using simple gestures (e.g., waving), saying a few words (e.g., "ball"), and understanding simple instructions (e.g., "pick up the toy").
18-24 months: Running, climbing, using two-word phrases (e.g., "more juice"), and recognizing familiar objects (e.g., "shoe").

Early Childhood (2-6 years):

2-3 years: Improved motor skills (e.g., throwing a ball), using short sentences, increased vocabulary (200+ words), and pretend play (e.g., playing house).
3-4 years: Improved balance and coordination (e.g., standing on one foot), using longer sentences, understanding basic grammar, and engaging in cooperative play (e.g., playing games with rules).
4-5 years: Writing some letters and numbers, improved fine motor skills (e.g., cutting with scissors), increased empathy (e.g., comforting a friend), and understanding the concept of time (e.g., morning, night).
5-6 years: Reading simple words (e.g., "cat"), counting (up to 20 or more), understanding basic math concepts (e.g., adding and subtracting), and developing friendships.

Middle Childhood (6-12 years):

6-8 years: Refining motor skills (e.g., skipping, catching a ball), increasing reading and writing abilities (e.g., reading a paragraph), problem-solving (e.g., solving puzzles), and understanding social norms (e.g., sharing, taking turns).
9-12 years: Developing abstract thinking (e.g., considering hypotheticals), expanding vocabulary (e.g., understanding figurative language), establishing a sense of self (e.g., personal interests), and navigating peer relationships (e.g., managing conflicts).

Adolescence (12-18 years):

12-14 years: Puberty (e.g., growth spurt, voice changes), cognitive development (e.g., increased critical thinking, considering consequences), and increased focus on peer relationships (e.g., forming cliques).
15-16 years: Identity exploration (e.g., exploring cultural or religious beliefs), increased independence (e.g., seeking privacy), and interest in romantic relationships (e.g., dating).
17-18 years: Preparing for adulthood (e.g., exploring career options, applying to college), developing a more complex sense of identity (e.g., integrating multiple aspects of self), and refining decision-making skills (e.g., evaluating long-term consequences, prioritizing goals). Additionally, adolescents may develop a stronger sense of empathy and moral reasoning (e.g., understanding ethical dilemmas, considering the perspectives of others).

This timeline provides a general outline of child development milestones, and individual experiences may vary based on factors such as genetics, environment, and cultural background.

Did your development roughly match the timeline of key developmental milestones listed here?

YesNoI don't know

Please provide us with any information about your development that you think may benefit your therapist to know:

Who is your medical doctor?

What is your medical doctor's phone number?

Who is your psychiatrist?

What is your psychiatrist's phone number?

Please list all medical or mental health conditions that you have now or have had previously (e.g., diabetes, depression, etc.):

Please list all medications you are currently taking and what they are prescribed to treat (e.g., Lipitor for cholesterol, Zoloft for depression, etc.):

Nightly Sleep:

Sleep Quality:

PoorFairGoodExcellent

How often do you exercise (i.e., planned structured, and repetitive physical activity)?

For how long do you exercise on average?

Eating Habits:

Please select any symptoms you have experienced in the past 6 months

If you wish, you may provide additional information about any symptoms listed above:

Cigarette Use:

Other Tobacco Use:

How frequently do you consume at least one drink containing alcohol

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have six or more drinks on one occasion?

How frequently do you use drugs (i.e., other than those prescribed by a doctor)?

Please name any drugs used during the past 6 months:

Have you ever felt like you should cut down on your drinking or drug use?

YesNo

Have people annoyed you by criticizing your drinking or drug use?

YesNo

Have you ever felt bad or guilty about your drinking or drug use?

YesNo

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

YesNo

Currently, how often are you having suicidal thoughts?

In the past, how often did you have suicidal thoughts?

Currently, how often are you hurting yourself (e.g., cutting)?

In the past, how often did you hurt yourself (e.g., cutting)?

Please select the best answer to describe the last time that you hurt or attempted to hurt yourself or others.

I have no history of self/other harmI have not hurt/attempted to hurt myself or others in at least 2 yearsI have not hurt/attempted to hurt myself or others in at least 1 yearI have not hurt/attempted to hurt myself or others in at least 6 monthsYes, I have hurt/attempted to hurt myself or others in the past 6 monthsYes, I have hurt/attempted to hurt myself or others in the past 3 months

What do you hope to accomplish in therapy?

List up to 3 things that will be different that indicate you will no longer need to attend therapy:

CLIENT INTAKE FORM

Demographic Information

Referral Information

Emergency Contact Person

Household Information

Employment Information

Previous Treatment

Developmental History

Health Information

Tobacco, Alcohol, and Substance Use

Please refer to this information to answer the following:

Health and Safety Check

Therapy Goals