INTAKE FORM
Please fill out this form and before your first session.

Please provide the following information and answer the questions below. Please note:
information you provide here is protected as confidential information.

Name *
First Last
Your answer
Birth Date *
MM
/
DD
/
YYYY
Marital Status: *
Partner's Name (type N if not applicable) *
First Last
Your answer
Birth Date *
today's date if single
MM
/
DD
/
YYYY
Please list any children/age:
Your answer
Address: *
Number and Street
Your answer
*
(City) (Prov) (Postal Code)
Your answer
Home Phone: *
(type "None" if you do not have a land line)
Your answer
*
May we leave a message?
Cell Phone *
(type "None" if you do not have a cell phone)
Your answer
*
May we leave a message?
E-mail: *
Your answer
May we email you? *
(*Please note: Email correspondence is not considered to be a confidential medium of communication.)
Referred by (if any):
Your answer
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *
*
Previous therapist/practitioner:
Your answer
Are you currently taking any prescription medication? *
*
Please list:
Your answer
Have you ever been prescribed psychiatric medication? *
Please list and provide dates:
Your answer
GENERAL HEALTH 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 types of exercise to you participate in?
Your answer
Please list any difficulties you experience with your appetite or eating patterns
Your answer
Are you currently experiencing overwhelming sadness, grief or depression? *
If yes, for approximately how long?
Your answer
Are you currently experiencing anxiety, panic attacks or have any phobias? *
If yes, when did you begin experiencing this?
Your answer
Are you currently experiencing any chronic pain? *
Do you drink alcohol more than once a week? *
How often do you engage recreational drug use? *
(Choose one)
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
Great
What significant life changes or stressful events have you experienced recently:
Your answer
FAMILY MENTAL HEALTH HISTORY:
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 (father, grandmother, uncle, etc.)
Alcohol/Substance Abuse *
Required
Indicate the family member’s relationship to you
Your answer
Anxiety
Indicate the family member’s relationship to you
Your answer
Depression *
Required
Indicate the family member’s relationship to you
Your answer
Domestic Violence *
Required
Indicate the family member’s relationship to you
Your answer
Eating Disorders *
Required
Indicate the family member’s relationship to you
Your answer
Obesity *
Required
Indicate the family member’s relationship to you
Your answer
Obsessive Compulsive Behavior *
Required
Indicate the family member’s relationship to you
Your answer
Schizophrenia *
Required
Indicate the family member’s relationship to you
Your answer
Suicide Attempts *
Required
Indicate the family member’s relationship to you
Your answer
ADDITIONAL INFORMATION:
Are you currently employed? *
If yes, what is your current employment situation:
Your answer
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 weakness? *
Your answer
What would you like to accomplish out of your time in therapy? *
Your answer
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