Amber Monroe, MFT 49337
Licensed Marriage and Family Therapist
8355 La Mesa Blvd.
La Mesa CA, 91942
ADULT INTAKE FORM
Please note: information provided on this form is protected as confidential information.
Referred By (if any):
DOB: Age: Gender:
Home Phone: May we leave a message? □ Yes □ No
Cell/Work/Other Phone: May we leave a message? □ Yes □ No
Email: May we leave a message? □ Yes □ No
*Please note: Email correspondence is not considered to be a confidential medium of communication.
Marital Status: □ Never Married □ Domestic Partnership □ Married □ Separated □ Divorced □ Widowed
Parental Status: □ I am a parent □ I want children one day □ I am unable to have children □ I do not want children
Employment Status: □ Working □ Unemployed □ Disability □ Care Provider □ Retired
Education Status: □ Graduated HS □ Some College □ Trade □ Associates □ Bachelors □ Masters □ MD □ In School
Who lives in your current home?
Religion/Spirituality? □ N/A
Mental Health Treatment History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? □ No □Yes
If yes please check all that apply: □ Outpatient □ Group Suport □ IOP □ PHP □ Residential □ Inpatient
Are you currently taking any prescription medication? □ Yes □ No If yes, please list:
Have you ever taken psychiatric medication in the past ? □ Yes □ No If yes, please list with approximate dates:
Mental Health Information
Current Symptoms: □ Depression □ Mania □ Anxiety □ Agitation □ Anger □ Panic □ OCD □ Low Libido
□ Low Self Esteem □ Poor Hygiene □ Ruminating Thoughts □ Isolation □ Eating Disorder □ Substance Use □ Social Phobia □ Other Phobia □ Hallucinations □ Paranoia □ Perfectionism □ Chronic Physical Pain
Current Stressors: □ Work □ School □ Relationship □ Children □ Family □ Finances □ Legal Problems □ Friends
Current Self Harm Behaviors: □ Cutting □ Hair Pulling □ Skin Picking □ Pinching □ Punching □ Burning □ Slapping
Do you have a history of self harming? □ Yes □ No
Current Safety Status: □ Thoughts of ending my life □ Plans to end my life □ Intent to end my life □ Thoughts of hurting others □ Plans to hurt others □ Intent to hurt others
Do you have a history of wanting to or attempting to end your life or harm others? □ Yes □ No
Trauma History: □ Physical □ Sexual □ Emotional/Mental □ Verbal □ Assault □ Witnessed DV □ Bullying
Substance Abuse History and Current use
Do you drink alcohol more than once a week? □ No □ Yes □ History of only
How often do you engage in recreational drug use? □ Daily □ Weekly □ Monthly □ History of only
General Health Information
How would you rate your current physical health? □ Poor □ Unsatisfactory □ Satisfactory □ Good Very □ Good
How would you rate your current sleeping health? □ Poor □ Unsatisfactory □ Satisfactory □ Good Very □ Good
How would you rate your current exercise health? □ Poor □ Unsatisfactory □ Satisfactory □ Good Very □ Good
How would you rate your current nutritional health? □ Poor □ Unsatisfactory □ Satisfactory □ Good Very □ Good
Where were you born & raised?
Who lived in your childhood home(s)?
What type of consequences were/are applied in your household growing up?
Does anyone in your immediate family struggle with drug abuse, alcohol abuse or an eating disorder?
Does anyone in your immediate family struggle with any psychiatric symptoms?
Who are your social supports? i.e. friends/boyfriend/girlfriend/spouse/parents/etc.?
What are your hobbies and interest?
What do you consider your strengths to be?
What do you consider your weaknesses to be?
What significant life changes or stressful events have you experienced recently?
What is most difficult for others to understand about you?
What is your goal for treatment?