Client Intake Form

Client Intake Form
This information will be kept in strict confidence. It will help me, as your therapist, ensure that the service I provide you with, is appropriate to your circumstances and that my duty of care towards you is upheld. Please complete all questions that you are able to and that feel relevant to our journey.
Name

First NameLast Name
Chosen Pronoun

he/himshe/herthey/themother
Date of Birth

DayMonthYear
Date
Cultural/Racial Identification
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Country CodePhone Number
Email
example@example.com
Can I leave a message via:

voicemailSMSemail
Next of Kin or Trusted Contact Details
Current Occupation or Area of Study/Interest
Medical/Biological Information
How would you rate your current physical health

ExcellentGoodSatisfactoryPoor
Any major current or chronic illness or injuries? Please give details of how you manage/ have managed this.
Do you smoke, consume alcohol or take any recreational drugs? Illicit or prescription. Please provide details of your relationship to these substances.(Again, I wish to assure you that this information will be held in confidence, without judgement, and is to ensure that I am able to care for you in this process)
Psychiatric/ Emotional Information
Have you ever received a psychiatric diagnosis? If yes, how have you managed it? Please give details.
Have you received counselling or psychotherapy before? If yes, for what reason? What was your experience like?
Are you currently experiencing overwhelming sadness, grief or depression? If yes, please describe.
Are you currently experiencing anxiety, panic attacks or do you have any phobias? If yes, please describe.
Have you experienced any significant life changes or stressful events recently?Please describe.
Have you ever had an attempt of suicide or participated in self-harm? If yes, please provide details of when and how.
Family/ Relational Information
How is your relationship to your current significant others? partner/children/parents/…?
Please describe any relevant past relationship history? (divorce, infidelity etc…)
What is your relationship to your family of origin (birth/childhood family)?
Do you have any family history of mental illness, addiction, violence, abuse, chronic illness? If so, please give brief details.
Treatment Information
What is the main issue you would like to work on with me as your therapist? What would you like to be different in your life when you’re done with therapy?
What do you consider to be some of your strengths?
What do you consider to be some of your personal growth edges (challenges)?
How important is spirituality in your life? What does that look like for you?
Is there anything else you’d like me to be aware of before we meet?
Thank you for your time in completing this form. I look forward to meeting you

and supporting you in undertaking this journey. Once again, if there is an urgent

concern that needs to be addressed, please contact your GP or an appropriate

local service for timely support. If a life is in danger, please contact 000

immediately.
Should be Empty:

Client Intake Form

Medical/Biological Information

Psychiatric/ Emotional Information

Family/ Relational Information

Treatment Information