Intake Questionnaire
Please fill in the information below and submot it at least 24 hours before your first session.
Please note: information provided on this form is protected as confidential information.
Full name:
Your answer
Date:
MM
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DD
/
YYYY
Date of Birth:
MM
/
DD
/
YYYY
Age:
Your answer
Gender:
Your answer
Parent/ Legal Gaurdian if under 18:
Your answer
Home phone:
Your answer
Cell phone:
Your answer
Work phone:
Your answer
Can I leave a message on your phone?
Required
Do I have permission to text you to arrange sessions?
Email:
Your answer
Place of Employment:
Your answer
Martial Status
Referred by (if any):
Your answer
History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.) Please list previous therapist/practitioner:
Your answer
Are you currently taking any prescription medication? If yes, please list:
Your answer
Have you ever been prescribed psychiatric medication? If yes, please list and provide dates:
Your answer
General and Mental Health Information
How would you rate your current physical health?
Please list any specific health problems you are currently experiencing:
Your answer
How would you rate your current sleeping habits?
Please list any specific sleep problems you are currently experiencing:
Your answer
How many times per week do you generally exercise? What if any types of exercise do you participate in?
Your answer
Please list any difficulties you experience with your appetite or eating problems:
Your answer
Are you currently experiencing overwhelming sadness, grief or depression? If yes, for approximately how long?
Your answer
Are you currently experiencing anxiety, panics attacks or have any phobias? If yes, when did you begin experiencing this?
Your answer
Are you currently experiencing any chronic pain? If yes, please describe:
Your answer
Do you drink alcohol more than once a week?
How often do you engage in recreational drug use?
Are you currently in a romantic relationship? If yes, for how long?
Your answer
On a scale of 1-10 how would you rate your relationship?
poor
exceptional
What significant life changes or stressful events have you experienced recently?
Your answer
Family Mental Health History
*Please note if this section causes you to feel unsettled in any way please take a few deep breaths and shift your attention to a happy memory. Stay with this memory until you feel settled and return to it as often as needed rather then just forcing yourself to continue. I do not require any details but I know the nature of these questions can be triggering for some. *
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.) Please also include if *you are currently struggling with any of the issues listed below.
Alcohol/Substance Abuse
Your answer
Anxiety
Your answer
Depression
Your answer
Domestic Violence
Your answer
Eating Disorders
Your answer
Any Other Mental Health Diagnosis
Your answer
Sexual abuse
Your answer
Physical abuse
Your answer
Emotional abuse
Your answer
Additional Information
Are you currently employed?
If you are employed, do you enjoy your work? Is there anything stressful about your current work?
Your answer
Do you consider yourself to be spiritual or religious? If yes, describe your faith or belief:
Your answer
What do you consider to be some of your strengths?
Your answer
What do you consider to be some of your weaknesses?
Your answer
What would you like to accomplish out of your time in therapy?
Your answer
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