Client Intake Form

  • CLIENT INTAKE FORM

    This form usually takes 5-10 minutes to complete. Completing this form is optional, and the choice to complete or not to complete this form will not affect your ability to be involved in therapy with your clinician. If you are filling this form out on behalf of someone else (e.g., child, foster child, etc.), most of the following questions are asking for information about that person, not you.
  • What is the name of your therapist (select all that apply)?*
  • Todays Date:
     - -
  • Client Birthdate:
     - -

  • Demographic Information

    If you are filling this form out on behalf of someone else (e.g., child, foster child, etc.), the following questions are asking for information about that person, not you.
  • Race/Ethnicity:
  • Sexual Orientation:
  • Relationship Status:
  • Current relationship length:
  • Religion & Spirituality
  • Highest Level of Education:

  • Referral Information

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

  • Emergency Contact Person

    This is the person you would like me to contact if there is an emergency.

  • Household Information

  • Employment Information

    If you are filling this form out on behalf of someone else (e.g., child, foster child, etc.), the following questions are asking for information about you, not that person.

  • Previous Treatment

    If you are filling this form out on behalf of someone else (e.g., child, foster child, etc.), the following questions are asking for information about that person, not you.
  • Have you been to therapy before?
  • If you have been to therapy, please select one or more of the following to rate your experience/s.

  • Developmental History

    If you are filling this form out on behalf of someone else (e.g., child, foster child, etc.), the following questions are asking for information about that person, not you.

  • 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?

  • Health Information

  • Nightly Sleep:
  • Sleep Quality:
  • How often do you exercise (i.e., planned structured, and repetitive physical activity)?
  • Eating Habits:
  • Please select any symptoms you have experienced in the past 6 months

  • Tobacco, Alcohol, and Substance Use

  • Cigarette Use:
  • Other Tobacco Use:

  • Please refer to this information to answer the following:

    1 Drink = 12 oz. of Beer, 8-9 oz. Malt Liquor, 5 oz. of Wine, 2-3 oz. of Liqueur, 1.5 oz. Hard Liquor
  • 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)?
  • Have you ever felt like you should cut down on your drinking or drug use?
  • Have people annoyed you by criticizing your drinking or drug use?
  • Have you ever felt bad or guilty about your drinking or drug use?
  • 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?

  • Health and Safety Check

    In case of emergencies, please call 9-1-1 or Tennessee Crisis Services at 855-274-7471
  • 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.

  • Therapy Goals

  • Should be Empty: