• INTAKE REFERRAL QUESTIONNAIRE

    Please complete all sections

  • This form is confidential and for internal use only. Retain in the individual's file per agency record retention policy.

  • Date*
     - -
  • DOB*
     - -
  • Format: (000) 000-0000.
  • I am the:*

  • SECTION 1 - PRESENTING CONCERNS

  • 2. How long have these concerns been present?*

  • SECTION 2 - TREATMENT HISTORY

  • 3. Have you ever received professional mental health treatment? (e.g., psychotherapy, medication)*
  • 5. Has your treatment been helpful?*
  • 6. Have you ever been hospitalized for mental health reasons?*

  • SECTION 3 - CURRENT SYMPTOMS

  • For questions 7-10, please indicate how often you have been bothered by the following over the past two weeks.

  • 7. Feeling nervous, anxious, or on edge*
  • 8. Not being able to stop or control worrying*
  • 9. Little interest or pleasure in doing things*
  • 10. Feeling down, depressed, or hopeless*

  • SECTION 4 - SAFETY

  • 11. Have you had thoughts of hurting yourself or wishing you were dead?*
  • 12. Have you intentionally hurt yourself (e.g., cutting), even if you did not want to die?*
  • 13. Have you used alcohol or drugs in a way that worries you, or would worry others?*

  • SECTION 4 - DAILY FUNCTIONING

  • 14. Is your mental health interfering with your daily life? (e.g., work, school, relationships)*
  • 15. Which areas are most affected? Select all that apply*

  • SECTION 5 - STRENGTHS & SUPPORT

  • 17. Do you have at least one friend or family member you can turn to for support?*
  • 18. How ready are you to make changes to improve your mental health?*
  • 19. How hopeful do you feel that your mental health can improve?*

  • SECTION 6 - SERVICE PREFERENCES

  • 20. What type of support are you most interested in? Select all that apply*
  • 21. If you have a general idea of when you're most available, please let us know. Select all that apply*
  • 22. When would you like to begin your therapy sessions?*

  • This form is confidential and for internal use only. Retain in the individual's file per agency record retention policy.

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