Psychotherapy Intake
Todays Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact (name and number):
*
Presenting problem (s) that brought you to seek counseling : (include onset of issue and intensity and duration):
*
Has this issue impacted your daily functioning? If so, how?
*
What goal(s) would like to work on in treatment:
*
How motivated are you to address issues and make changes?
*
What has been going well for you?
*
What are your hobbies/What do you enjoy doing during your free time?
*
Do you have a primary care physician?
*
Yes
No
Physician's name:
Do you have any allergies?
*
Do you have any medical conditions?
*
Have you had in-patient or out-patient treatment?
*
In-patient
Out-patient
None
If yes, please supply following information below: when, where, length of stay/how long/how often, reason, outcome, discharge recommendation (if any):
Please list all previous mental health diagnosis:
*
Current psychiatric medications:
*
Past psychiatric medications:
*
Do any of your family members have a psychiatric history?
*
Yes
No
If yes, please explain:
What is your current living situation?
*
Relationship status:
*
Single
Married
Divorced
Widowed
Separated
Partner
Do you have children?
*
Yes
No
If so, how many, what are their ages, and do they reside with you?
Please provide brief description of your relationship (if applicable) with:
Mother:
Father:
Siblings:
Children:
Significant other:
What are your Support Systems and Community Resources?
*
Spiritual belief system, if any:
*
Highest grade completed:
*
Do you have any learning disabilities?
*
Yes
No
If yes, please explain:
Employment:
*
Full time
Part time
Retired
Disabled
Student
Homemaker
Unemployed
How satisfied are you with your current employment?
*
Military History:
*
None
Yes/ non-combat
Yes/ combat
If yes, what branch and years active:
Do you have any current legal involvement?
*
Yes
No
If yes, please explain:
Is there a family history of substance abuse?
*
Yes
No
If yes, please explain:
Please list and substances you have used. Please list: 1.)Substance, 2.)Age of first use, 3.)if you are currently still using, 4.)how often and 5.)if it has impacted you in a negative way and how
*
Have you had substance abuse treatment?
*
Please check off any symptoms you are experiencing now or have experienced in the last two weeks:
*
anxiety
depression
poor concentration
restlessness
obsessive thoughts
risky behavior
feeling guilty
feeling detached from self or others
family conflict
avoidance
difficulty falling asleep
mood swings
feeling hopeless
lying
panic attacks
emotionally numb
fatigue
confusion
loss of motivation
phobia
racing thoughts
crying spells
isolation
feeling people are against you or out to get you
self-harming behavior
interpersonal conflict
hallucinations
suicidal thoughts
homicidal thoughts
harm to others
poor self esteem
Other
Do you have a history of trauma or abuse?
*
Have you ever had feelings that you didn't want to live?
*
Yes
No
If so, when did you last have these feelings?
Have you had thoughts of killing yourself?
*
Yes
No
If so, did you have a plan and when?
Have you attempted suicide?
*
Yes
No
If so, how long ago and did you need medical care?
Submit
Should be Empty: