Transform & Thrive Therapy Intake Form

Transform & Thrive Therapy Intake Form

Please complete each section of this form with as much information as possible. All information on this form is strictly confidential and will become part of your file.
Client Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Gender*
Age*
Birth Date*

MonthDayYear
Date
Which category best describes you?
Relationship
What is your relationship status?*

MarriedNever MarriedSeparatedDomestic PartnershipWidowedOther
If applicable, how would you rate your relationship well-being?

1

2

3

4

5

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7

8

9

10

1 is Not Functioning, 10 is No Problems
Employment
What is your employment status?*

EmployedUnemployedRetiredSelf-employedDisabledStudentHomemakerOther
Family & Household
Including yourself, how many people live in your household? *

Please indicate if there is a family history of any of the following conditions;*

	Yes	No	Indicate Family Member(s)
Anxiety
Depression
Substance Abuse / Alcohol
Arrested/Incararated
Bipolar 1 or 2
Schizophrenia
Suicide Attempt
Domestic Violence

Please list any additional mental health history for family members (including children, parents, grandparents, siblings, aunts, uncles, etc.) not listed above. *
How would you rate your family relationship?*

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9

10

1 is Not functioning, 10 is No Problems
If anything, what would you change about your familial relationships?*
Mental Health History
Have you previously received any type of mental health services?*

YesNo
Please elaborate on mental services previously received.
Are you currently on psychiatric medication?*

YesNo
Please list psychiatric medicines that you took or are taking currently.
General Health Information
How would you rate your physical health condition? *

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2

3

4

5

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8

9

10

1 is Very Poor, 10 is Excellent
How often do you exercise? *

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3

4

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10

1 is None, 10 is Very Often
How would you describe your general appetite?*

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10

1 is Very Poor, 10 is Very Hungry
How would you describe your stress level throughout the day?*

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2

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10

1 is Very Relaxed, 10 is Very Stressed
Do you drink alcohol?*

YesNo
How many drinks do you have weekly?
Do you use recreational or other prescription drugs (not psychiatric drugs)?*

YesNo
Please elaborate on your recreational and/or prescription drug usage.
Primary Reason for Seeking Services

Please answer all of the statements below that describe your concerns.
Symptoms:*

Anger Management/AggressionSchool/Learning/ Developmental IssuesWork/Employment IssuesAnxietyGrief/LossWeight/Eating DisordersDepressionMarriage/Relationships IssuesSuicidal Thoughts/Hurting SelfCrying spellsAffairHomicidal Thoughts/Harming OthersSleeping ProblemsSeparation/DivorceFinancial ProblemsTrauma/Experienced Life Threatening EventFamily/Relationship IssuesSexual ConcernsAlcohol UsageParenting/Behavior ProblemsProblems with PornographyDrug UsageMental Confusion/PsychosisFrequent Lying/DeceitfulnessLoss of Interest in ActivitiesPoor ConcentrationPanic AttacksDecreased MotivationRacing or Scrambled ThoughtsGambling ProblemsDifficulty Enjoying ThingsExcessive FearHigh/Low EnergyFeelings of InadequacyDestructive BehaviorsGuilt/ShameWithdrawing from Others/IsolationInsecurityHopelessnessLonelinessImpulsive BehaviorsFlashbacksThoughts of Running AwayFeelings of FrustrationMood SwingsMedical ConcernsHear/See Things Others Do NotOther
I often experience;*

fear of many thingsguiltpanic attacksavoiding peoplehaving nightmaresanxiety, nervousnessdiscomfort in social situationssexual issuesOther
I often have;*

suicidal thoughtsmemory problemssleeping disorderstruggled to explain myself to othersobsessive thoughtsviolent thoughtsstress and tensionmedical concernsfatiguework problemsOther
I often feel;*

lonelyemptysadhopeless about the futureexcessive guiltsuspiciousOther
Please summarize your goals or desired outcomes for counseling/therapy:*
Should be Empty:

Transform & Thrive Therapy Intake Form

Client Information

Relationship

Employment

Family & Household

Mental Health History

General Health Information

Primary Reason for Seeking Services