Adult Intake Form
Name
Last Name
Address
Street Address
City
Address
Street Address Line 2
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Format: (000) 000-0000.
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Date of Birt
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Month
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Day
Year
Date
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Gender
In an Emergency - emergency contact name and number
GP name and number
List of medical conditions and medications
Have you ever had previous therapy/counselling of any kind? If yes, when, with whom, and for how long? What did you find helpful about this therapy
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Occupational History - student / employment and details
Educational History: Please describe yourself as you can remember in your school years
Social History: Can you please describe yourself during your school / adolescent years
Any learning difficulties
Any history of bullying
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Family Background - who is in your family or origin and your family now?
Please describe your relationship with your family - parents, siblings and/or current partner
Any loss in your family
Any history in your family of mental health concerns
Social supports - friends, family, work, special interests
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Reason for seeking therapy now
What do you hope to be able to achieve?
Current stressors?
How do you manage these stressors currently
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Type a question
In the last year have you experienced any significant changes?
Are you currently experiencing anxiety
Please Select
Yes
No
Please describe your symptoms
Are you currently experiencing low-mood or depression
Please Select
Yes
No
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Please describe your symptoms
Sleep disturbance?
Please Select
Yes
No
Hallucinations / Paranoia?
Please Select
Yes
No
Addiction to alcohol, drugs, sex or gambling?
Please Select
Yes
No
Any history of physical, emotional, neglect or sexual abuse?
Please Select
Yes
No
Any history of self-harm?
Please Select
Yes
No
Ever seriously considered suicide or felt like harming someone else?
Please Select
Yes
No
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Is there anything else that would be useful for me to know
Is there anything else that would be useful for me to know
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