Intake Form - Psychotherapy Adult
Please provide the following information for our records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality as therapy.
Email address *
Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender Identification *
Your answer
Marital Status *
Address (street, city, province, postal code) *
Your answer
Phone Number *
Your answer
May I leave a message at the phone number you listed? *
Who referred you to my practice?
Are you currently receiving psychiatric, professional counselling or psychotherapy services elsewhere? *
If yes, where?
Your answer
Have you attended psychotherapy in the past? *
If yes, who provided the psychotherapy?
Your answer
If yes, why did you seek out psychotherapy in the past?
Your answer
What was helpful about your previous experiences in psychotherapy? What was unhelpful?
Your answer
Are you currently taking any prescribed psychiatric medications? (Anti depressants, anti anxiety etc.) *
If yes, please list the medications here.
Your answer
If no, have you been prescribed medications in the past? If yes, please list your previous medications here.
Your answer
How would you rate your current physical health? *
Poor
Excellent
Please list any persistent physical symptoms of health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.):
Your answer
Are you having any problems with your sleep habits? *
If yes, check where applicable:
How many times per week do you exercise? For how long? *
Your answer
Are you having any difficulty with appetite or eating habits? *
If yes, check where applicable.
Have you experienced significant weight change in the last two months? *
Do you regularly consume alcohol? *
In a typical month, how often do you consume more than 4 drinks in a 24 hour period? *
Your answer
How often do you engage in recreational drug use? *
Have you had suicidal thoughts recently? *
Have you had suicidal thoughts in the past? *
Are you currently in a romantic relationship? *
If yes, how long have you been in this relationship?
Your answer
If yes, how would you rate the quality of this relationship?
Poor
Excellent
Have you experienced any of these issues? *
Yes
No
Extreme depressed mood
Wild mood swings
Rapid speech
Extreme anxiety
Panic attacks
Phobias
Sleep disturbances
Hallucinations
Unexplained losses in time
Unexplained losses in memory
Alcohol/Substance abuse
Frequent body complaints
Eating disorders
Body image problems
Repetitive thoughts (e.g. obsessions)
Repetitive behaviours (e.g. frequent hand washing or checking)
Homicidal thoughts
Suicide attempts
In the past year, have you experienced any significant life stressors or life changes? *
If yes, please describe:
Your answer
Are you currently employed? *
If yes, who is your current employer and what is your position?
Your answer
If yes, how satisfied are you with your job?
Not Happy
Very Happy
Please list any work related stressors, if any:
Your answer
Do you consider yourself to be religious?
If yes, how do you describe your faith?
Your answer
If no, do you consider yourself to be spiritual?
Has anyone in your family (grandparents, parents, siblings, or other relatives) experienced difficulties in the following areas?
Yes
No
Depression
Bi-Polar
Anxiety disorders
Panic attacks
Schizophrenia
Alcohol/Substance abuse
Eating disorders
Trauma history
Learning disabilities
Suicide attempts
What do you consider to be your strengths? *
Your answer
What do you like most about yourself? *
Your answer
What are some effective coping strategies that you have learned? *
Your answer
What are your goals for psychotherapy? *
Your answer
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