McFarland Marriage and Family Therapy
Initial Assessment Intake Form: Please complete this form before your first hourly session appointment.
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Gender
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Female
Male
Transgender
Marital Status
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Single
Married
Dating/Partnered
Engaged
Living Together
Divorced
Separated
Widowed
Dating/Relationship History
Are you currently in a romantic relationship?
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Yes
No
How long have you been in this romantic relationship?
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Do you feel safe in your current romantic relationship?
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Yes
No
Unsure
What is your sexual orientation?
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Lesbian
Heterosexual
Gay
Bisexual
Questioning
Other
Choose any relationship issues that you'd like to address in counseling:
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None
Communication Patterns
Infidelity
Age Differences
Growing Apart
Long Distance Relationship
Pre-Marital Counseling
Deciding About Having Children
Co-Parenting
Unforgiveness
In-Law Issues
Gender Roles
Work/Home Balance
Abuse (Physical, Emotional, Psychological)
Spiritual Beliefs
Relationship Symbols/Rituals
Leisure Activities
Friends of the Opposite Sex
Codependency (Feeling responsible for the other partner's feelings)
Boundaries in Marriage
Boundaries with Children
Personal Boundaries while Dating
Other
Primary Care Physician
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First Name
Last Name
Address of Primary Care Physician
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician Phone Number
*
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Area Code
Phone Number
Current Therapist / Counselor
First Name
Last Name
Current Therapist's Office Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Therapist's Office Phone Number
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Area Code
Phone Number
Please list the problem(s) which you are seeking help?
Current Symptoms
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Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Paranoia
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
OCD Behaviors
Specific Phobia
Attention and Focus
Other
Have you ever had feelings or thoughts that you didn't want to live?
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Yes
No
Do you currently feel that you don't want to live?
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Yes
No
How often do you have these thoughts?
When was the last time you had thoughts of dying?
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On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?
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1
2
3
4
5
6
7
8
9
10
Weak
Strong
1 is Weak, 10 is Strong
On a scale of 1 to 10 (10 being most stressful), how stressful is your current career?
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1
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
On a scale of 1 to 10 (10 being fabulous), how would you rate the quality of your current dating/marriage relationship?
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1
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
Suicide Risk Assessment
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Rows
Yes
No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?
Do you currently have a plan to kill or harm yourself?
Medical History
Do you have any allergies? (If yes, please list them)
Current Weight
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Current Height
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List all current prescription medications and how often you take them
Current medical problems
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Past medical problems, nonpsychiatric hospitalization, or surgeries
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For women only:
Have you every lost a child via abortion, miscarriage, stillbirth, or other circumstances?
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Yes
No
Other
Describe any history of Grief or Loss of a loved one
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Psychiatric History:
Outpatient treatment
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Yes
No
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization
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Yes
No
If yes, Please describe when, where, by whom, and nature of treatment
Past Psychiatric Medications
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
Rows
Have you ever taken it?
Dates
Dosage
Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other medications?
Family Psychiatric History
Has anyone in your family been diagnosed by a licensed physician/therapist and treated for:
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Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcohol Abuse
Recreational Drug Abuse
Learning Disability
Autism
Personality Disorder of Any Kind (Borderline, Narcissistic, Histrionic)
Other
Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment?
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Exercise Level
Do you exercise regularly?
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Yes
No
How much time each day do you exercise?
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Type of Exercise Done Most Often
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Describe your Eating Habits on a Typical Day (include Water Intake)
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How many hours of sleep do you get a night?
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None
1-4 hours
5-6 hours
7-9 hours
More than 9 hours
Describe Any Nightmares or Recurring Dreams and how often they Occur
Religious/Spiritual Beliefs
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Atheist
Agnostic
Christian
Buddhist
Islam
Catholic
Non-Denominational
Hinduism
Taoism
Other
Check if you have ever tried the following
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
How often do you partake in recreational drug use (refer to the previous question)?
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How many caffeinated beverages do you drink a day?
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Tobacco History
Have you ever smoked cigarettes?
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Yes
No
How many packs per day?
How many years?
Family Background and Childhood History:
Were you adopted?
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Yes
No
Briefly describe your childhood
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List your siblings and their ages:
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Were your parents married?
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Yes
No
Describe your nuclear family (family grown up in).
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Single Biological Parent Home
Two Biological Parent Home
Two Parent Blended Family (Biological Parent Married your Step Parent)
Same Sex Parent Home
Other
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.
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Personal History
Highest grade completed?
*
Are you currently:
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Employed
Student
Unemployed
Disabled
Retired
Do you have any children?
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Yes
No
Please list ages and gender:
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Have you ever been arrested?
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Yes
No
Type a question
Do you have a current open legal case (other than traffic violations)?
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Yes
No
If yes to previous question, please describe:
Have you ever had the Department of Social Services involved with your family?
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Yes
No
If yes to previous question, please briefly describe including if the case is currently open.
Additional information the therapist should know
Emergency Contact
*
First Name
Last Name
Address of Emergency Contact
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Emergency Contact
*
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Area Code
Phone Number
Signature
*
Guardian Signature (if under age 18)
Upload a picture of Driver's License/ID
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Upload a picture of the front and back of your Insurance Card
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