New Client Intake Questionnaire
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  • New Client Intake Questionnaire

    Background Information
  • Today's Date*
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • OK to leave a message?*
  • Format: (000) 000-0000.
  • OK to leave a message?
  • Relationship Status*

  • Please list the NAME, SEX, and BIRTHDATES of ALL those living in your home besides yourself. This would include children, spouses, partners and/or any relatives.

  • Reason(s) for seeking counseling:

  • MEDICAL HISTORY

  • Format: (000) 000-0000.
  • Have you ever had a head injury?*
  • Date of Last Medical Exam:*
     - -
  • Format: (000) 000-0000.
  • Do you or anyone in your immediate family have a history of alcohol/drug abuse or are you currently struggling with this?*

  • MARRIAGE / FAMILY HISTORY

  • Is your marriage an area of struggle or strength for you?*

  • SOCIAL HISTORY

  • Do you have a close friend(s)?*
  • Which of the following devices do you use regularly? (Check all that apply)*

  • On a typical day, how much time do you spend on each of the following activities?

  • Social media (Instagram, TikTok, Facebook, Snapchat, etc.)*
  • Messaging (texting, WhatsApp, etc.)*
  • Online browsing/News*
  • Streaming shows or videos (YouTube, Netflix, etc.)*
  • Gaming*
  • Gambling*
  • Shopping*
  • On an average weekday, about how many hours do you spend using screens in total (all devices combined)?*
  • On an average weekend day, about how many hours do you spend using screens in total (all devices combined)?*

  • SPIRITUAL HISTORY

  • Do you currently practice a spiritual tradition?*
  • Are your spiritual beliefs helpful or a hindrance to you?*
  • Will your spiritual beliefs be an important part of counseling?*

  • EDUCATION HISTORY

  • How many schools did you attend through high school?*
  • Do you have a diagnosed learning disability?*

  • EMPLOYMENT HISTORY

  •

  • LEGAL HISTORY

  • Are you currently involved in any legal litigation?*
  • Do you have any prior convictions?*

  • DRUG & ALCOHOL HISTORY

  • Have you ever received treatment for substance abuse?*
  • Do you ever use illegal drugs?*

  • PRESENT LIFE

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  • Please indicate all that apply for yourself currently. Couples will each need to fill out one.*

  • GROWING UP

  • DEVELOPMENTAL HISTORY: Please indicate all that apply. To the best of your ability indicate what you know about growing inside your mother's womb, and then also birth to 3 years old.*
  • EXPERIENTAL HISTORY: Please indicate all that apply regarding growing up in your family of origin.*
  • Overall, you would describe your family-life growing up as...*
  • Have you ever had ANY TYPE OF COUNSELING BEFORE?*
  • Have any of your family members ever had any type of counseling before?*
  • Have you ever seriously considered or attempted suicide?*
  • Have any of your family members ever seriously considered, attempted or completed suicide?*
  • Are you currently taking any medications?*
  • Are any of your family members currently taking any medications?*
  • Do you eat balanced meals regularly?*
  • Do you regularly exercise?*
  • Do you make yourself sick, because you feel uncomfortably full?*
  • Do you worry you have lost control over how much you eat?*
  • Have you recently lost or gained more than 15 pounds in a 3-month period?*
  • Do you believe yourself to be fat when others say you are too thin?*
  • Would you say that food dominates your life?*
  • Do you use the internet to look at pornography?*
  • Do you have any concerns about the counseling process?*
  • Are you involved in any service, church, or charitable work?*
  • Have you received a copy of the Professional Disclosure Statement?*
  • I understand that payment is due at time of services.*
  • Is there anything further that you feel you would like to explain or add to any of the above?*
  • I have done my absolute best to answer these questions honestly and as complete as possible.*
  • Date*
     - -
  • Should be Empty: