Client Intake Questionnaire

Please fill in the information below. Please note: information provided on this form is protected as confidential information.

Name of client:

Date:

Date

Parent/Legal Guardian if under 18:

Address:

Home Phone:

Format: (000) 000-0000.

Cell/Work/Other Phone:

Format: (000) 000-0000.

Email:

example@example.com

DOB:

Grade:

Gender:

Referred By (if any):

Has the client previously received any type of mental health services (psychotherapy, psychiatric services, etc?)

If yes, please list name and city:

Is the client currently taking any prescription medication? If yes, please list:

Date started:

Date

How would you rate the client's current physical health? (Please select one)

PoorSatisfactoryGoodVery Good

Please list any specific health problems the client is currently experiencing:

How would you rate the client's current sleeping habits? (Please circle one)

PoorSatisfactoryGoodVery Good

Please list any specific sleep problems the client is currently experiencing:

Does the client play any sports or exercise? What types of sports/exercise do they participate in?

Please list any difficulties the client experiences with their appetite or eating problems:

Is the client experiencing overwhelming sadness, grief or depression?

If yes, for approximately how long?

Is the client currently experiencing anxiety, panics attacks or have any phobias?

If yes, when did they begin experiencing this:

What significant life changes or stressful events has the client experienced recently:

What dates/times are you and the client available to meet during the week:

What is your main area of concern that you would like us to focus on in session:

Family Mental Health History: In the section below, identify if there is a family history of any of the following - Anxiety, Depression, Domestic Violence, Eating Disorders, Obsessive Compulsive Behavior, Schizophrenia, Suicide Attempts. If yes, please indicate the family member's relationship to you in the space provided (e.g. father, grandmother, uncle, etc):

Anything else we should know that might assist us in helping you?