ADULT INTAKE QUESTIONAIRE

Journey To Healing, PLLC

2812 1st Ave North, Suite 425 Billings, MT 59101
ADULT INTAKE QUESTIONAIRE
PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR KNOWLEDGE.

NOT ALL QUESTIONS MAY BE RELEVENT TO YOU.
GENERAL
DATE

MonthDayYear
Date
CLIENT NAME
PREFERRED NAME
CLIENT DATE OF BIRTH

MonthDayYear
Date
PROVIDER-Primary Care
HOW DID YOU HEAR ABOUT US? WHO REFERRED YOU?
DO YOU HAVE ANYBODY ELSE WORKING WITH YOU THAT YOU WANT ME TO SHARE INFORMATION WITH? (DOCTORS, EMPLOYERS, FAMILY MEMBERS, CASE MANAGERS, ETC.)
WHAT IS THE MAIN REASON YOU ARE COMING TO COUNSELING? WHAT SPECIFIC SYMPTOMS ARE YOU EXPERIENCING? WHEN DID THE SYMPTOMS START?
WHAT ARE YOUR GOALS FOR COUNSELING?
WHAT ARE THE PRIMARY STRESSORS IN YOUR LIFE?
DEMOGRAPHIC
WHAT RACE/ETHNICITY DO YOU IDENTIFY WITH? WHAT DOES YOUR CULTURE MEAN TO YOU?
WHAT IS YOUR SEXUAL ORIENTATION/IDENTITY?
ARE YOU RELIGIOUS OR BELONG TO A SPECIFIC RELIGION? HOW INVOLVED ARE YOU? WHAT DOES YOUR RELIGION MEAN TO YOU?
ARE YOU EMPLOYEED AND/OR ATTEND SCHOOL? WHAT IS YOUR OCCUPATION OR DEGREE? DO YOU ENJOY YOUR JOB AND/OR SCHOOL?
WHAT IS YOUR HIGHEST LEVEL OF EDUCATION?
HEALTH AND MENTAL HEALTH
HAVE YOU EVER HAD ANY SERIOUS MEDICAL CONDITIONS OR INJURIES? WHAT WERE THEY? HOW OLD?
DO YOU CURRENTLY HAVE ANY SERIOUS MEDICAL CONDITIONS? WHAT ARE THEY?
HAVE YOU EVER BEEN DIAGNOSED WITH A MENTAL ILLNESS? WHAT MENTAL ILLNESS? WHO DIAGNOSED YOU? WHAT TREATMENT DID YOU RECEIVE?
HAVE YOU PREVIOUSLY BEEN SEEN BY A MENTAL HEALTH PROFESSIONAL? WHO? WHEN?
HAVE YOU EVER BEEN HOSPITALIZED FOR MEDICAL OR MENTAL ILLNESS? PLEASE DESCRIBE.
DO YOU HAVE ANY CURRENT OR PAST MEDICATIONS FOR MENTAL OR MEDICAL ILLNESS? WHAT WERE THEY?
WHO IS YOUR PRIMARY CARE PROVIDER? WHEN WAS YOUR LAST CHECKUP?
DID YOU EXPERIENCE ANY DEVELOPMENTAL DELAYS OR HAVE LEARNING DIFFICULTIES AS A CHILD?
WHAT WAS SCHOOL LIKE FOR YOU?
DO YOU HAVE A HISTORY OF ABUSE, NEGLECT, OR EXPERIENCED ANY OTHER TRAUMATIC EVENT(S)? (CAR ACCIDENTS, DEATH OF LOVED ONES, SEXUAL ASSAULT, WITNESSING ABUSE? WITNESSING SUBSTANCE ABUSE, POVERTY, BULLYING, ETC.)
HAVE YOU EVER HAD SUICIDAL THOUGHTS AND/OR ATTEMPTED SUICIDE? PLEASE DESCRIBE.
HAVE YOU EVER SELF HARMED? PLEASE DESCRIBE?
YOU HAVE A HISTORY OF SUBSTANCE ABUSE? AT WHAT AGE DID YOU START USING SUBSTANCES? PLEASE DESCRIBE.
DO YOU CURRENTLY USE ILLEGAL DRUGS, ALCOHOL, OR TOBACCO PRODUCTS? WHAT PRODUCTS DO YOU USE? HOW OFTEN?
HAS ANYONE EVER EXPRESSED CONCERN OVER YOUR SUBSTANCE USE? WHAT WERE THEIR CONCERNS?
FAMILY OF ORIGIN
WHAT WAS YOUR RELATIONSHIP LIKE WITH YOUR PARENTS AND SIBLINGS GROWING UP?
WHAT IS YOUR RELATIONSHIP LIKE WITH YOUR PARENTS AND SIBLINGS NOW?
IS THERE A HISTORY OF MENTAL ILLNESS IN YOUR FAMILY? PLEASE DESCRIBE.
DO YOUR PARENTS OR GRANDPARENTS HAVE A HISTORY OF TRAUMA, ABUSE, DOMESTIC VIOLENCE, OR SUBSTANCE ABUSE? PLEASE DESCRIBE?
RELATIONSHIPS
ARE YOU MARRIED/DIVORCED/WIDOWED? HOW LONG?
WHAT IS YOUR RELATIONSHIP LIKE WITH YOUR CURRENT PARTNER/SPOUSE?
DO YOU HAVE ANY CHILDREN? HOW MANY & WHAT AGES?
WHAT IS YOUR RELATIONSHIP LIKE WITH YOUR CHILDREN?
WHAT IS YOUR CURRENT LIVING SITUATION? WHO DO YOU LIVE WITH?
OTHER
WHAT DO YOU ENJOY DOING? DO YOU HAVE ANY HOBBIES OR SPECIAL INTERESTS?
WHAT ARE YOUR STRENGTHS?
WHO SUPPORTS YOU? WHO DO YOU TURN TO FOR HELP?
HOW DO YOU USUALLY COPE WITH STRESS?
IS THERE ANYTHING ELSE YOU WOULD LIKE ME TO KNOW?
Should be Empty:

Journey To Healing, PLLC

ADULT INTAKE QUESTIONAIRE

GENERAL

DEMOGRAPHIC

HEALTH AND MENTAL HEALTH

FAMILY OF ORIGIN

RELATIONSHIPS

OTHER