Client Intake
Name *
Current Date *
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Date of Birth *
Gender *
Address *
Age *
Home Phone
Work Phone
Cell Phone *
Can we text regarding appointment days and times? *
Email *
Occupation and Employer *
Emergency Contact (Name and Relationship to you) *
Emergency Contact Phone *
Relationships
Who are the people living in your home? Please list Name, Relationship, and Age. ex. (Jane Doe, Sister, 45). *
Who are other family members NOT living in your home? Please list Name, Relationship, and Age. (example: Jane Doe, Sister, 45) *
I am currently... *
Required
If married or life partnered, how many years? *
What is your total number of marriages/life partnerships? *
Do you have children? If so, how many children? *
If you have children, pick the following that applies. *
Required
If you do not have custody but have visitation rights, how often?
Do you have any difficulty getting along with your family members? Please explain. *
Self Evaluation and Family History
Please complete the following statements
I feel happiest... *
If I could change one thing about myself... *
What I regret the most... *
The most important thing to me is... *
Do you or your family members have a history of the following?
Answer none, now, or past and please explain.
Physical abuse or violent relationships? You? Who in your family? *
Sexually abusive relationships? You? Who in your family? *
Emotional or physical neglect? You? Who in your family? *
Serious illness or death of a family member? You? Who in your family? *
Divorce? You? Who in your family? *
A family member in jail or prison? You? Who in your family? *
Depression, anxiety, etc.? You? Who in your family? *
Addiction: alcohol, sex, food, shopping, pornography, and drugs? You? Who in your family? *
Suicide? You? Who in your family? *
Do you have any spiritual or religious issues that you would like me to consider in our work? *
How do you enjoy spending your spare time? *
Who do you feel closest to? *
Who referred you to my practice and what is their phone number? *
Do you have any medical concerns? If yes, please elaborate below. *
What are your current prescription medications? If so, please list the name and dosage below. (example- Prozac 20mg) *
Do you have sleep issues? If yes, please explain below. *
What issues would you like to address in therapy? *
What have I not asked that you'd like me to know? *
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