Client Intake Questionnaire

Please fill in the information below and bring it with you to your first session. Please note: information provided on this form is protected as confidential information.

Name

Date

Parent/Legal Guardian (if under 18): Address:

ParentLegal Guardian if under 18

Address

May we leave a message? YesNo May we leave a message? Yes/No

May we leave an email message? Yes/No *Please note: Email correspondence is not considered to be a confidential medium of communication.

Home Phone

Cell/Work/Other Phone

Email

example@example.com

DOB

Age

Gender

Referred By if any

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc?

NoYes, previous therapist/practitioner:

previous therapistpractitioner

If yes please list

Are you currently taking any prescription medication? If yes, please list:

If yes please list and provide dates

Date

Have you ever been prescribed psychiatric medication?Yes If yes, please list and provide dates:

General and Mental Health Information

1. How would you rate your current physical health? (Please circle one)

Poor

Satisfactory

Please list any specific health problems you are currently experiencing

2. How would you rate your current sleeping habits? (Please circle one)

Please list any specific sleep problems you are currently experiencing

3. How many times per week do you generally exercise? What types of exercise do you participate in?

3 How many times per week do you generally exercise

What types of exercise do you participate in

4. Please list any difficulties you experience with your appetite or eating problems:

Yes/No

5. Are you currently experiencing overwhelming sadness, grief or depression?

Yes/No

If yes for approximately how long

6. Are you currently experiencing anxiety, panics attacks or have any phobias? No/Yes

If yes when did you begin experiencing this

7. Are you currently experiencing any chronic pain?

If yes please describe

8. Do you drink alcohol more than once a week?

9. How often do you engage in recreational drug use? Daily WeeklyMonthly

10. Are you currently in a romantic relationship?

If yes for how long

On a scale of 110 with 1 being poor and 10 being exceptional how would you rate your relationship

11 What significant life changes or stressful events have you experienced recently

Family Mental Health History In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (e.g. father, grandmother, uncle, etc

Anxiety Depression Domestic Violence Eating Disorders Obesity Obsessive Compulsive Behavior Schizophrenia Suicide Attempts

yes / no yes / no yes / no yes / no yes / no yes / no yes / no yes / no yes / no

No 1. Are you currently employed?Yes If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

2. Do you consider yourself to be spiritual or religious?

If yes, describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

5. What would you like to accomplish out of your time in therapy?