Intake Questionnaire

Today's date

MonthDayYear

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home phone

Area CodePhone Number

Can I leave you a message on home phone?

YesNo

Cell phone

Area CodePhone Number

Can I leave you a message on cell phone?

YesNo

Work phone

Area CodePhone Number

Can I leave you a message on work phone?

YesNo

E-mail

Can I email you at this email address?

YesNo

Emergency contact name

Emergency contact number

Area CodePhone Number

Date of your birth

MonthDayYear

Place of your birth

Education:

Occupation and employer:

Relationship status:

How did you hear about my practice?

What made you want to enter therapy now?

What are the main concerns you’re seeking help with?

What would you like to accomplish in therapy?

RELATIONSHIPS

Present spouse or partner(s) (name, occupation and quality of your current relationship):

Past marriage(s) or partnerships (years and nature of the relationship such as distant, abusive, loving etc.):

List any children, step-children and grandchildren (names, ages and nature of your relationship):

Parents or step-parents (names, age or year of death, cause of death, occupation):

Father

Mother

Step-parents

If your parents divorced, how old where you at the time and how did it affect you?

List any siblings (name and age) and describe your relationship with each:

Other current significant relationships:

MEDICAL HISTORY

Childhood medical history (diseases, vaccinations, broken bones, allergies, etc.):

Current medical doctor(s) (name and phone):

Any other medical professionals you are currently seeing (name and phone):

Adult medical history (major medical problems, surgeries, injuries, illnesses, allergies, etc.):

List all medications you’re presently taking and for what, as well as important past medications:

List alternative therapies that you’ve used or are currently involved in:

List any supplements that you’re taking:

List any past or present drug or alcohol use including: What you’ve used and how much? Has use ever affected your work or relationships? What treatment have you received?

Have you ever had difficulty with your eating habits? If yes, please describe:

Past and present psychotherapy (estimated length of treatment, therapist’s name, initial reason for therapy, brief description of the relationship, how it was helpful or not, and why it ended):

Do you have any previous suicide attempts, self-destructive behaviors, or violent behaviors? Please indicate your age, circumstances and whether it led to hospitalization or legal problems:

Have you ever been hospitalized for psychological concerns? If yes, please provide details:

FAMILY HISTORY

Family medical history (such as cancer, epilepsy, etc.):

Family history of alcoholism, mental illness,or violence (suicide, depression, hospitalizations, abuse, etc.):

LEGAL ISSUES

Have you been involved in any type of lawsuits? If yes, what type of lawsuits and are any suits still ongoing?

SPIRITUAL HISTORY

Do you have a religious or spiritual identity or orientation?

CURRENT ISSUES

What are your main worries, fears or challenges right now?

How would you describe your social support network?

What do you consider your strengths?

What are your most important hopes or dreams?

What are your self-care routines (exercise, daily diet, hobbies, etc.)?

Please add any other information that may be helpful to our work together.

INTAKE QUESTIONNAIRE