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
Emergency contacts relationship to you
I am here for

Court EvaluationPsychological TestingTherapy
Gender / Pronouns (if applicable)
Race / Ethnicity
Religious Background
Cultural Considerations
Sexual Orientation
Relationship Status

SingleMarriedSeparatedDivorcedWidowed
How long has this been your relationship status
In a relationship are you satisfied?

YesNoUnsure
Do you feel supported by your partner?

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?
Are you currently a student?

YesNo
Did you / do you receive exceptional student education (ESE) services?

YesNo
Do you have any disabilities / impairments to be aware of?
Are you currently working?

Part-timeFull-timeNot currently employed
If no, when did you last work?
Occupations
Typical weekly work schedule
At which office location are you interested in receiving therapy?

ClearwaterBrandonVirtualIn-office/Virtual (mix)
How will you be covering the cost of therapy services?

InsuranceSelf-Pay
If Insurance, what company?
How were you referred to me as a therapy provider?

Website/ DrValPsychDoc.comPsychology TodayAlmaFriend/ Family MemberOther
What are your primary problems / concerns at this time? How long have they been an issue?*
How would you rate the intensity of these problems or concerns?

Not at allMild IntensityModerate IntensityStrong IntensityExtreme Intensity
How have you tried to cope with your struggles up until now?
How motivated are you to resolve these issues 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
Do you have any concerns about sexual functioning?

YesNoUnsure
How many times per week do you exercise? For how long?
Do you smoke/vape nicotine?

YesNo
If yes, how often throughout the day?
Do you drink alcohol?

YesNo
If yes, how often / how many drinks per week?
Have you ever "blacked out", not remembered doing something, or gotten somewhere without knowing how you got there?

YesNo
If yes, please describe:
Do you / Have you used any illegal drugs?

YesNo
If yes, which drugs?

MarijuanaCocaineLSDHeroinOpiatesOther
How often / for how long?
Do you, or does someone else think you need to cut down, or stop using drugs or drinking?

YesNo
Have you noticed any recent changes in your weight?

IncreaseDecreaseNo change
Have you noticed any recent changes in your appetite?

IncreaseDecreaseNo change
How many hours of sleep do you typically get each night?
Do you have issues

Falling asleepStaying asleepBothNone
Have you received mental health treatment with a psychologist, psychiatrist, or counselor in the past?

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?
Thoughts of harming self?

CurrentPastNone
If so, how often?
Thoughts of harming others?

CurrentPastNone
If so, how often?
Self-harming behavior?

CurrentPastNone
If so, how often and through what means?
Attempted suicide?

YesNo
If yes, when and how did you attempt?
Have you ever had a head injury or loss of consciousness?

YesNo
Do you have a history of seizures?

YesNo
Have you ever had a stroke or experienced loss of oxygen to the brain?

YesNo
Have you ever experienced a traumatic event or significant loss?

YesNo
If yes please describe:
Have you ever experienced any form of abuse?

NoneSexualPhysicalVerbalPsychological
If yes, at what age(s) did the abuse occur? Who was the perpetrator, if known?
Are you currently, or do you consider yourself likely to be involved in litigation in the near future?

YesNo
Are you currently, or have you previously served in the military?

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?