Therapy Intake Questionnaire

Valerie Andersen, PSYD || Licensed Psychologist || PY9730

Confidential Intake Questionnaire

Please complete the following information so that I can more fully understand your concerns.
Full Name
Date of Birth

MonthDayYear
Date
Age
Email Address
example@example.com
Address
City
State
Zip Code
Emergency Contact Name
Phone
Format: (000) 000-0000.
Emergency contacts relationship to you
Court EvaluationPsychological TestingTherapy
Gender / Pronouns (if applicable)
Race / Ethnicity
Religious Background
Cultural Considerations
Sexual Orientation
SingleMarriedSeparatedDivorcedWidowed
How long has this been your relationship status
YesNoUnsure
YesNoUnsure
How many people can you count on for emotional support and friendship?
What makes someone trustworthy, in your opinion?
Please list any family members currently living with you, their occupation, age.
Including yourself please list any family members who have had significant emotional mental health or addiction problems
Who in your family do you feel closest to?
Most distant from?
In most conflict with?
What is your highest level of education?
Do you have a trade, hold any degrees, areas of specialty?
YesNo
YesNo
Do you have any disabilities / impairments to be aware of?
Part-timeFull-timeNot currently employed
If no, when did you last work?
Occupations
Typical weekly work schedule
ClearwaterBrandonVirtualIn-office/Virtual (mix)
InsuranceSelf-Pay
If Insurance, what company?
Website/ DrValPsychDoc.comPsychology TodayAlmaFriend/ Family MemberOther
What are your primary problems / concerns at this time? How long have they been an issue?*
Not at allMild IntensityModerate IntensityStrong IntensityExtreme Intensity
How have you tried to cope with your struggles up until now?
Not at allA littleSomewahtModeratelyExtremely
Describe in detail a time in your life when you felt genuinely happy and optimistic about the future. (i.e. What were you involved in? Who was present? What was meaningful and brought you sense of purpose? What did you recognize as achievements?)
What area's of life do you feel are going really well RIGHT NOW? (list all that apply)
List as MANY of your strengths as you can?
List ONE of your weaknesses?
What physical / medical problems do you have now?
Please list any previous medical concerns
Please list any current medications.
Physician who prescribed medication
YesNoUnsure
How many times per week do you exercise? For how long?
YesNo
If yes, how often throughout the day?
YesNo
If yes, how often / how many drinks per week?
YesNo
If yes, please describe:
YesNo
MarijuanaCocaineLSDHeroinOpiatesOther
How often / for how long?
YesNo
IncreaseDecreaseNo change
IncreaseDecreaseNo change
How many hours of sleep do you typically get each night?
Falling asleepStaying asleepBothNone
YesNo
If yes what were your concerns?
For what reason did you discontinue treatment?
Have you ever been hospitalized for mental health concerns?
Have you ever engaged in any of the following?
CurrentPastNone
If so, how often?
CurrentPastNone
If so, how often?
CurrentPastNone
If so, how often and through what means?
YesNo
If yes, when and how did you attempt?
YesNo
YesNo
YesNo
YesNo
If yes please describe:
NoneSexualPhysicalVerbalPsychological
If yes, at what age(s) did the abuse occur? Who was the perpetrator, if known?
YesNo
YesNo
If yes, please specify the dates of service.

MonthDayYear
Date
Is there any other information that would help me understand you, and / or your concerns? If so, please include detailed information here.
I verify that the above information is accurate, to the best of my knowledge:
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Have you ever engaged in any of the following?