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
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First Name
Last Name
Client's Date of Birth
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Month
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Day
Year
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.
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How would you rate your current physical health? Please list any specific health problems you are currently experiencing.
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How would you rate your current sleeping habits? Please list any specific sleep problems you are currently experiencing.
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Are you currently experiencing overwhelming feelings of sadness, grief, or depression? If yes, for approximately how long? Provide any additional information if desired.
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Do you currently have, or have you in the past, had suicidal thoughts?
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Please Select
Yes, currently
Yes, in the past
No
Have you ever attempted suicide?
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Please Select
Yes
No
Do you currently have, or have you in the past, had thoughts or urges to harm others?
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Please Select
Yes, currently
Yes, in the past
No
Have you ever been hospitalized for a psychiatric need?
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Please Select
Yes
No
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.
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Are you currently experiencing excessive anger or rage? If yes, for approximately how long? Provide any additional information if desired.
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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?
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Do you consider yourself to be spiritual or religious? If yes, please describe your faith or belief.
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How would you describe your gender?
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Please Select
Female
Male
Non-binary
Transgender
Prefer not to self-describe
Prefer not to say
How would you describe your sexual orientation?
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Please Select
Straight (Heterosexual)
Gay
Lesbian
Bisexual
Queer
Prefer not to self-describe
Prefer not to say
What do you consider to be your strengths?
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HISTORY
Have you previously received any type of mental health services? If yes, how was the experience?
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Are you currently taking any prescription medications? If yes, please list them.
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Is there any history of mental illness in your family? If yes, please explain.
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PARENTING
Please list the names and ages of any children you are currently raising or have raised in the past.
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If you birthed any children, how was your prenatal and birth experience? If you have not, please put N/A.
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If you birthed any children how was your postnatal (0-6 months) experience? If you have not, please put N/A.
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How would you describe your relationship status?
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Please Select
Single
In a relationship
Engaged
Married
Separated
Divorced
Widowed
If you are currently in a coparenting relationship, how would you describe it? If not, please put N/A.
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Overall, how is your parenting experience?
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What is the most stressful aspect of parenting?
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What is the most rewarding aspect of parenting?
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COUNSELING GOALS
What would you like to accomplish during your time in therapy?
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How will we know when your goals are being met?
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What else would you like me to know?
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Submit
Should be Empty: