New Psychotherapy Client Intake Form Clinical Background Information

Are you completing this form for yourself or for a child?
My name:
Patient Name:
Education/Employment
Are you currently enrolled in school?
If yes, which school are you attending?
Highest level of education completed:
Are you currently working?
If so, are you working full-time, part-time, or is this not applicable?
With whom do you currently live:
Current Grade Level:
Has your child ever repeated or skipped a grade?
Does your child have an IEP or 504?
How would you best describe your child's school behavior and attitude?
Reasons for Seeking Help
What are you currently experiencing that causes distress?
When did these problems begin and what was happening in your life at that time?
What are your goals for counseling?
Psychiatric & Medical History
Have you been diagnosed with any psychiatric or mental help problems?
Have you been hospitalized for psychiatric reasons?
Have you been diagnosed with any physical health problems?
Which physical health problems?
Are you taking any psychiatric medications?
If yes, please list your medications:
Please provide the name of your psychiatrist and/or general practitioner:

Family Medical/Psychiatric History:

Rows	Mother	Father	Siblings	Maternal side	Paternal side
Anxiety disorder
Mood disorder (depression/bipolar)
Substance abuse (alcohol/drugs)
Schizophrenia/psychosis
Learning disabilities/problems
Health problems

Family of Origin history
Were your parents:
Who raised you:
How would you describe your childhood?
What was your birth order?
E.g., 1st, 2nd, 3rd, etc.
Out of how many children?
E.g., 2, 3, 4, etc.
Trauma History
Have you ever experience any abuse?
Has your child experienced any of the following? (check all that apply)
Should be Empty: