Intake Questionnaire (Part 1) for MA Residents
Part 1: Life, Status, Health, & Mental Health assessment questions
The Counseling Center at CELA - Massachusetts Residents Form
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Email *
Initials (two letters only, one for first name / one for last name) *
What brings you here? *
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *
What is your gender *
Are you currently employed? *
How old are you?
What is your orientation?
Have you ever been in counseling or therapy before? *
Are you currently experiencing overwhelming sadness, grief, or depression? *
Are you currently suicidal? *
When was the last time you had a plan for suicide? *
Are you currently experiencing anxiety, panic attacks, or have any phobias? *
Have you been moving or speaking so slowly that other people might have noticed? Or the exact opposite--been so fidgety or restless that you have been moving around a lot more than usual? *
Do you have any problems or worries about intimacy? *
Feeling down, depressed, or hopeless?
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Are you currently taking any medication? *
Are you having any trouble falling asleep, staying asleep, or sleeping too much? *
Are you feeling bad about yourself--or that you're a failure or have let yourself or your family down? *
Any trouble concentrating on things like reading or watching TV? *
Are you currently experiencing any chronic pain? *
Thoughts that you would be better off dead or of hurting yourself in some way? *
How would you rate your current sleeping habits? *
How would you rate your current eating habits? *
Do you consider yourself to be religious? *
What religion do you identify with? *
Do you consider yourself spiritual? *
How would you rate your current physical health? *
How often do you drink alcohol? *
Who referred you to The Counseling Center at CELA? *
What country are you in? *
Which state are you in (if in the USA)? *
Completing this form *
Write your initials (two letters, one for your first name and one for your last name as you did at the beginning of this form) and the time and the date that you finished filling out this form in the spaces provided below. Providing your initials as well as the date and time you completed this form acknowledges that you: (1) have read and understood each individual question and the sections of this form, and the information requested and/or provided; and (2) have provided information that is accurate and correct to the best of your knowledge.
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Please sign/type your initials in the space below to complete this form. Thank you! --- The Counseling Center at CELA. *
A copy of your responses will be emailed to the address you provided.
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