Client Intake Form
to be completed prior to the first session
Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Gender:
*
Female
Male
Transgender - identify as female
Transgender - identify as male
Nonbinary
Genderfluid
Gender nonconforming
Other
Marital Status
*
Unmarried
Partnered
Married
Separated
Divorced
Widowed
Email
*
example@example.com
Is it ok to email?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
With whom do you live?
*
Alone
My spouse
Child(ren)
Parents
Other family member(s)
Friend(s)
Roommate(s)
Other
Your Phone Number
*
Please enter a valid phone number.
Is it ok to leave a voicemail?
*
Yes
No
Is it ok to text?
*
Yes
No
In case of emergency, who should your therapist contact?
*
First Name
Last Name
Emergency contact's relationship to you:
*
Emergency contact's phone number:
*
Please enter a valid phone number.
Mental Health
Reason(s) for Counseling:
*
ADHD
Academic Distress
Anger Management
Anxiety
Autism or Developmental Difference
Behavioral Issue
Coping Skills
Decision-making
Depression
Divorce
Domestic Violence
Eating Difficulties
Family Issues
Grief & Loss
Identity Issues
LGBTQ+
Low Self-esteem
Mood Swings
Panic Attacks
Parenting
Relationship Issues
Social Anxiety
Social Isolation
Social Skills
Women's Issues
Other
Have you ever been in counseling or therapy before?
*
Yes
No
If yes, please state when, for how long and what reason:
Have you ever been hospitalized for a psychiatric or mental health reason?
*
Yes
No
If yes, please state when, for how long and what reason:
Have you ever taken medication for a psychiatric or mental health reason?
*
Yes
No
If yes, please list the medication(s) taken, for how long, and for what reason
Have you felt depressed lately?
*
Yes
No
If yes, for how long?
A few days
A week
A month
2-3 months
4-6 months
A year
Other
Have you had suicidal thoughts recently?
*
Yes
No
If yes, how often?
Frequently
Sometimes
Rarely
If yes, what was your plan?
If yes, did you intend to complete the act?
Yes
No
Have you had suicidal thoughts in the past?
*
Yes
No
If yes, how long ago?
How often did you have these thoughts
Frequently
Sometimes
Rarely
Medical Health
How is your health at this time?
*
Excellent
Good
Fair
Poor
Do you have any medical conditions?
*
Yes
No
If yes, please list:
Are you on medication(s) for physical/medical reasons?
*
Yes
No
If yes, please list current medication(s) and reason:
Are you having any problems with sleep?
*
Sleeping too much
Not sleeping enough
Waking up in the night
Difficulty falling asleep
Difficulty staying asleep
Nightmares or disturbing dreams
Other
Are you having problems with eating?
*
Yes
No
If yes, mark all that apply:
Eating too much
Not eating enough
Bingeing
Purging (vomiting, laxatives)
Restricting (limiting food, dieting)
Pica (eating non-food items)
Picky eater
Food allergies
Other
How much alcohol do you consume?
*
None
Daily
Once a month
2-3 times per month
1-2 dinks per week
3-4 drinks per week
5-6 drinks per week
7 or more drinks per week
Other
How much marijuana do you use (smoke, vape, edibles)?
*
None
Daily
Multiple times per day
1-2 times per week
3-4 times per week
5 or more times per week
Other
Education & Employment
What is the highest level of education yo have completed?
*
Middle school
GED/High school diploma
Trade school
Bachelor's degree
Graduate degree
Other
Are you currently employed?
*
No job, not in school
No job, in school
Yes, part-time
Yes, full-time
Yes, sporadically
Working and also in school
Other
If yes, what is your position?
Are you happy in your current position?
Yes
No
Sometimes
Not applicable
Does your work make you stressed?
Yes
No
Sometimes
Not applicable
Additional Information
What are your strengths/what do you like about yourself?
*
List areas you feel you need to develop:
*
What are your goals for therapy/what you would like to accomplish?
*
What are some ways you cope with life's obstacles and stress?
*
Payment Preference:
*
Health Insurance
Company EAP Program
Self-Pay (credit card, PayPal, Zelle, Venmo)
Other
Who is your health insurance provider? (write "none" if you do not have health insurance)
*
Health Insurance Member Number:
Health Insurance Group Number:
By submitting this form, I am acknowledging that I have chosen to receive mental health services in the form of evaluation and/or psychotherapy from Kelly Patrick, LMHC & A Kind Place, LLC. My decision is voluntary and I understand that I may terminate these services at any time. I also understand that during the course of treatment I may need to discuss material of an upsetting nature in order to resolve my problems. Further, I understand it cannot be guaranteed that I will feel better after completion of treatment. (Agree and click "Submit")
*
I agree
Signature
*
Continue
Continue
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