New Client Intake Questionnaire

New Client Intake Questionnaire

Background Information
Today's Date*

MonthDayYear
Date
REFERRAL SOURCE*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address Line 2

CityState

Postal / Zip Code
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
OK to leave a message?*

YESNO
Home Phone
Please enter a valid phone number.
OK to leave a message?

YESNO
Place of Employment
City of Employment
Relationship Status*

SingleCohabitatingMarriedWidowedDivorced
How long?*
Previous Marriages (Please give number / year married / year divorced or widowed.)*
Please list the NAME, SEX, and BIRTHDATES of ALL those living in your home besides yourself. This would include children, spouses, partners and/or any relatives.
LIST ALL: Name & Relationship / Sex / Date of Birth*
Reason(s) for seeking counseling:
How long have these issues been troubling you?*
What made you decide to come in to counseling right now?*
What are you hoping to achieve in counseling?*
What are your goals for counseling?*
Is there any current crisis in your life right now? (any danger, family reunions, tests, etc.)*
MEDICAL HISTORY
Current Physician*

First NameLast Name
Physician Phone*
Please enter a valid phone number.
Current Medical Conditions (Type NONE, if non-applicable.)*
Current Medications / Dosage / Reason for taking (Type NONE, if non-applicable.)*
Have you ever had a head injury?*

YESNO
What are your menstrual cycles like? (Type N/A, if non-applicable.)*
Date of Last Medical Exam:*

MonthDayYear
Date
Emergency Contact*

First NameLast Name
Emergency Phone*
Please enter a valid phone number.
Emergency [contact] Relationship*
Do you or anyone in your immediate family have a history of alcohol/drug abuse or are you currently struggling with this?*

YESNO
MARRIAGE / FAMILY HISTORY
Marriage Date(s)...list divorce/separation date(s), if applicable *
Is your marriage are area of struggle or strength for you?*

YESNO
SOCIAL HISTORY
Do you have a close friend(s)?*

YESNO
How often do you get together?*
Which of the following devices do you use regularly? (Check all that apply)*

Smartphone/iPadTelevision/Streaming deviceGaming consoleOther
On a typical day, how much time do you spend on each of the following activities?
Social media (Instagram, TikTok, Facebook, Snapchat, etc.)*

Less than 30 minutes30 minutes – 1 hour1–2 hours2–4 hours4–6 hoursMore than 6 hoursNONE
Messaging (texting, WhatsApp, etc.)*

Less than 30 minutes30 minutes – 1 hour1–2 hours2–4 hours4–6 hoursMore than 6 hoursNONE
Online browsing/News*

Less than 30 minutes30 minutes – 1 hour1–2 hours2–4 hours4–6 hoursMore than 6 hoursNONE
Streaming shows or videos (YouTube, Netflix, etc.)*

Less than 30 minutes30 minutes – 1 hour1–2 hours2–4 hours4–6 hoursMore than 6 hoursNONE
Gaming*

Less than 30 minutes30 minutes – 1 hour1–2 hours2–4 hours4–6 hoursMore than 6 hoursNONE
Gambling*

Less than 30 minutes30 minutes – 1 hour1–2 hours2–4 hours4–6 hoursMore than 6 hoursNONE
Shopping*

Less than 30 minutes30 minutes – 1 hour1–2 hours2–4 hours4–6 hoursMore than 6 hoursNONE
Other (please specify):
On an average weekday, about how many hours do you spend using screens in total (all devices combined)?*

Less than 2 hours2–4 hours4–6 hours6-8 hoursMore than 8 hours
On an average weekend day, about how many hours do you spend using screens in total (all devices combined)?*

Less than 2 hours2–4 hours4–6 hours6-8 hoursMore than 8 hours
SPIRITUAL HISTORY
In which spiritual tradition were you raised, if any?*
Do you currently practice a spiritual tradition?*

YESNO
Are your spiritual beliefs helpful or a hindrance to you?*

HelpfulHindrance
Will your spiritual beliefs be an important part of counseling?*

YESNO
How does your spirituality affect your life in general and/or daily life?*
EDUCATION HISTORY
How many schools did you attend through high school?*

1234Other
What were your grades like?*
What was your overall feeling towards school when you were growing up?*
Do you have a diagnosed learning disability?*

YESNO
If YES, please explain.
EMPLOYMENT HISTORY
Please list your most recent jobs, including seasons in the home (most recent first).*
Are you satisfied with your current employment situation?*

1

2

3

4

5

6

7

8

9

10

1 is Unsatisfied, 10 is Very Satisfied
LEGAL HISTORY
Are you currently involved in any legal litigation?*

YESNO
Do you have any prior convictions?*

YESNO
If YES, please list.
DRUG & ALCOHOL HISTORY
Have you ever received treatment for substance abuse?*

YESNO
Do you ever use illegal drugs?*

YESNO
If YES, when?
How much alcohol to you consume?*
How many cigarettes do you smoke per day?*
How much caffeine do you consume per day?*
PRESENT LIFE
Please indicate your general mood level for the last month by circling one or more of the numbers on the scale below.*

1

2

3

4

5

6

7

8

9

10

1 is Extremely Depressed, 10 is Extremely Happy
Please indicate your current level of anxiety/nervousness over the last month by circling one or more of the numbers on the scale below.*

1

2

3

4

5

6

7

8

9

10

1 is Extremely Peaceful, 10 is Extremely Anxious
Please indicate all that apply for yourself currently. Couples will each need to fill out one.*

Threats of killing or hurting selfThreats of killing someone elseHear or see things others do notExposure to traumatic eventAvoidance of responsibilityOver-tired or easily fatiguedUnable to keep friendsPre-occupation with sexFrequent physical complaintsShortness of breathExaggerated sense of worthMood goes up and down a lotSad most of the timeStrong sense of right and wrongTics/other involuntary movementsNot interested in thingsHard to concentratePrescription drug abuseHard PornagraphyAbortionAny kind of reference to killing or hurting selfAny kind of reference to killing someone elseSelf injuryBed wettingSecretiveEating problemsDay wettingAngry moodNightmaresLots of EnergyHopelessnessFrequent conflictDelinquencySpiritual problemInterrupting others frequentlyRecurring thoughtsDifficulty sleepingDomestic violenceInternet relationship(s)Purging FoodHording thingsDietingFire SettingStealingIrritable moodMuscle TensionWorry a lotVandalism"Flash-backs"Sexual difficultyHelplessnessFearfulNight terrorsWeight problemArrestsArgumentativeRacing thoughtsHurting animalsTearfulLyingBlame othersRepetitive BehaviorsDrug/Alcohol AbusePoor decisionsExtreme shynessLack confidenceActing without thinkingHard to remember thingsHair pullingSoft pornographyInfidelity/AffairBody-Image issuesNone of theseOther
GROWING UP
DEVELOPMENTAL HISTORY: Please indicate all that apply. To the best of your ability indicate what you know about growing inside your mother's womb, and then also birth to 3 years old.*

Pregnancy Difficulties/AbnormalitiesWalking/gross motor problemsAlcohol/illegal drugs during pregnancyHand coordination/fine motor problemsPoor attachment to parents/caregiversDid not meet developmental milestonesAway from parents for a long timeMedication during pregnancyDifficulties during pregnancySpeech/Language problemOverly social/friendlyProblems eating as a babyMedication during pregnancyPremature birthExcessive fearsDifficult to comfortEating non foodsExposure to leadProblems sleeping as a babyOverweight at birthUnderweight at birthNone of these
EXPERIENTAL HISTORY: Please indicate all that apply regarding growing up in your family of origin.*

Death in the familyBasic needs not met (food/shelter/clothes)Living in constant fearStrong feelings of guilt or shameAbortion (if so, when?)Alcohol or drug abuse (indicate by whom and when)Sexual or physical abuse (indicate by whom and when)Known family history of physical or sexual abuseUnemploymentViolence in homeParental IllnessWeight IssuesBody-Image issuesFinancial stressFrequent movesEmotional movesParental/Guardian separationPurgingCrime victimNatural disasterParental DivorceExtreme Dieting
Overall, you would describe your family-life growing up as...*

SupportiveLovingChaoticConfusingAffirmingStrictHostileSafeUnsafeNegative
Have you ever had ANY TYPE OF COUNSELING BEFORE?*

YESNO
If YES, what was the reason and focus of therapy? If NO, type N/A.*
If YES, what kind of therapy was it? (Descriptions of memorable interactions) If NO, type N/A.*
Length of therapy
What was the quality of relationship with therapist (any problems)?
What characteristics do you look for in a therapist?
Why did you stop treatment?
What did you learn that was useful?
How was the experience disappointing?
Was there anything he or she never addressed? (events/situations/symptoms/issues)
What did you like and not like about your previous therapy?
What would happen if therapy was successful? Would there be a downside? Would anyone in your life have a problem with that?*
Have any of your family members ever had any type of counseling before?*

YESNO
If YES, please list the dates, with whom and for what purpose.
Have you ever seriously considered or attempted suicide?*

YESNO
If YES, please explain.
Have any of your family members ever seriously considered, attempted or completed suicide?*

YESNO
If YES, please explain.
Are you currently taking any medications?*

YESNO
If YES, please list the medications, purpose, and prescribing physician.
Are any of your family members currently taking any medications?*

YESNO
If YES, please list the medications, purpose, and prescribing physician.
Take a moment to describe any of the above you checked that you feel might need some explanation such as your view point on alcohol use, internet relating, traumatic events, etc.
Do you eat balanced meals regularly?*

YESNO
Do you regularly exercise?*

YESNO
If YES, please specify (exercise).
Do you make yourself sick, because you feel uncomfortably full?*

YESNO
Do you worry you have lost control over how much you eat?*

YESNO
Have you recently lost or gained more than 15 pounds in a 3-month period?*

YESNO
Do you believe yourself to be fat when others say you are too thin?*

YESNO
Would you say that food dominates your life?*

YESNO
Do you use the internet to look at pornography?*

YESNO
Describe what is causing you the most stress and/or concern at this time.*
Do you have any concerns about the counseling process?*

YESNO
What is the best part of your current life?*
What are your greatest accomplishments?*
What do you believe are your 3 greatest strengths?*
What do you believe are your 3 top growth areas?*
Are you involved in any service, church, or charitable work?*

YESNO
What are your URGENT goals?*
What are you doing to attain your goals?*
Have you received a copy of the Professional Disclosure Statement?*

YESNO
I understand that payment is due at time of services.*

YESNO
Is there anything further that you feel you would like to explain or add to any of the above?*

YESNO
I have done my absolute best to answer these questions honestly and as complete as possible.*

YESNO
Client Signature*

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Date*

MonthDayYear
Date
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New Client Intake Questionnaire

Please list the NAME, SEX, and BIRTHDATES of ALL those living in your home besides yourself. This would include children, spouses, partners and/or any relatives.

Reason(s) for seeking counseling:

MEDICAL HISTORY

MARRIAGE / FAMILY HISTORY

SOCIAL HISTORY

SPIRITUAL HISTORY

EDUCATION HISTORY

EMPLOYMENT HISTORY

LEGAL HISTORY

DRUG & ALCOHOL HISTORY

PRESENT LIFE

GROWING UP