New Client Intake Form:
Full Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
May we leave a message?
Cell
Work
Email
Date of Birth
-
Month
-
Day
Year
Date
Marital Status
*
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other (Please specify...)
Referred By (If Any)
Have you previously received any type of mental health services (Psychotherapy, Psychiatric services, etc.)?
If yes previous therapist/practitioner:
Are you currently takin any prescription medication?
If yes, please list"
Have you ever been prescribed psychiatric medication?
If yes, please list:
How would you rate your current...
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Physical Health
Sleepin Habits
Mental Health
Please list any specific sleep problems you are currently experiencing:
How many times per week do you generally exercise?
Whats types of exercise do you participate in? (if any)
Please list any difficulties you experience with your appetite or eating problems:
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?
Are you currently experiencing any chronic pain?
Do you drink alcohol more then one a week?
How often do you engage in recreational drugs use?
Are you currently in a romantic relationship?
If yes, for how long?
On a scale from 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
What significant life changes or stressful events have you experienced recently?
Alcohol/Substance Abuse
List Family Member
Anxiety
Depression
List Family Member
Domestic Violence
Eatin Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts
Are you currently employed?
IF yes, what is your currently employment situation?
Do you enjoy your work? Is there anything stressful about your current work?
Do your consider yourself to be spiritual or religious?
If yes, 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?
What would you like to accomplish out of your time in Coaching/Counseling?
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