Tosa Pediatrics Parent Mental Health Intake

Tosa Pediatrics Peripartum & Parenting Therapies Intake Questionnaire

COMPLETE ONLY IF THE PARENT IS THE ONE RECEIVING INDIVIDUAL THERAPY SERVICES - NOT TO BE COMPLETED FOR CHILD
Client's Name*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
PRESENTING CONCERN
What brings you to counseling at this time? Is there something specific, such as a particular event? Please be as detailed as possible.*
How would you rate your current physical health? Please list any specific health problems you are currently experiencing. *
How would you rate your current sleeping habits? Please list any specific sleep problems you are currently experiencing. *
Are you currently experiencing overwhelming feelings of sadness, grief, or depression? If yes, for approximately how long? Provide any additional information if desired.*
Do you currently have, or have you in the past, had suicidal thoughts?*
Have you ever attempted suicide?*
Do you currently have, or have you in the past, had thoughts or urges to harm others?*
Have you ever been hospitalized for a psychiatric need?*
Are you currently experiencing anxiety, panic attacks, or do you have any phobias? If yes, for approximately how long? Provide any additional information if desired.*
Are you currently experiencing excessive anger or rage? If yes, for approximately how long? Provide any additional information if desired.*
Please provide any additional information about concerning symptoms you are currently experiencing.
ADDITIONAL INFORMATION
Are you currently employed? If yes, what is your job type and employer? *
Do you consider yourself to be spiritual or religious? If yes, please describe your faith or belief. *
How would you describe your gender?*
How would you describe your sexual orientation?*
What do you consider to be your strengths?*
HISTORY
Have you previously received any type of mental health services? If yes, how was the experience?*
Are you currently taking any prescription medications? If yes, please list them. *
Is there any history of mental illness in your family? If yes, please explain. *
PARENTING
Please list the names and ages of any children you are currently raising or have raised in the past.*
If you birthed any children, how was your prenatal and birth experience? If you have not, please put N/A.*
If you birthed any children how was your postnatal (0-6 months) experience? If you have not, please put N/A.*
How would you describe your relationship status?*
If you are currently in a coparenting relationship, how would you describe it? If not, please put N/A.*
Overall, how is your parenting experience?*
What is the most stressful aspect of parenting?*
What is the most rewarding aspect of parenting?*
COUNSELING GOALS
What would you like to accomplish during your time in therapy?*
How will we know when your goals are being met?*
What else would you like me to know?*
Should be Empty:

Tosa Pediatrics Peripartum & Parenting Therapies Intake Questionnaire

PRESENTING CONCERN

ADDITIONAL INFORMATION

HISTORY

PARENTING

COUNSELING GOALS