New Client Intake Forms - Adult
Please complete the following questionnaire. 
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Email *
Client Name *
First and last name
Date of Birth:
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Age of Client: *
Street Address: 
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City, State, Zip: 
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Email(s): *
Telephone number(s): Home: Work: *
Telephone number(s): Cell/Home etcl:
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Type of telemedicine services sought (secure online video platform via Psychology Today): *

Briefly describe your reason(s) for seeking help at this time:

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What do you wish to accomplish through the process of therapy: 

Have you ever been in therapy/counseling before?
If yes, briefly describe the reason(s), dates(s) and length of treatment

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Was it a positive experience? What was helpful about it?

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Personal Data

Date of Birth

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MM
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Place of Birth *

Mother’s condition during pregnancy (as far as you know):

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Check any of the following that apply during your childhood:

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Required
Any previous or current mental health diagnosis? *
Please list any previous psychotropic or prescribed medication: *
Please list any current psychotropic or prescribed medication: *
Any diagnosed health conditions? *

Health during childhood? List Illnesses: 

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Health during adolescence? List Illnesses: 

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Height?

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Weight?
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Any accidents? *

Present interests, hobbies, and activities:

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How is most of your free time occupied?:

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What is the last grade of school completed?

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Scholastic abilities, strengths and weaknesses:

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Were you ever bullied or severely teased?

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Did you make friends easily? Do you keep them?

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If you use alcohol or drugs please answer the following:

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Daily
Weekly
Monthly
Rarely
Never
Marijuana
Alcohol
Nicotine
Cocaine
LSD
Mushrooms
Prescription Drugs
Oher

Have you ever been arrested for driving while intoxicated? (Drivers) If yes, when? Dates:

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Has your drug/alcohol use been pointed out by anyone in or outside of the family as a problem? If so, please explain:

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Does your personality change when you use? How:

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Has your behavior become more hostile and caused conflict with anyone else when you’ve been under the influence of drugs/alcohol? With Whom?

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Have you ever had periods of time that you cannot remember the next day after you have been influence of drugs/alcohol? How often does this occur and when is the last time?

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Does or has anyone in your family abused drugs or alcohol? Who and to what extent?

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What are your five main fears?
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Have your (client) ever attempted suicide?
If yes, please describe: 

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Have you (client) ever seriously contemplated suicide?

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Are you (client) currently having suicidal thoughts?

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Do you (client) ever hear or see things that other people cannot hear or see?

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Have you (client) ever committed a violent act or crime?
If yes, please describe: 

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Have you (client) ever been arrested?
If yes, please describe: 

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Are you (client) presently taking any medication? □ Yes □ No
If yes, please describe: ___

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What do you (client) enjoy doing in your spare time? 

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Are there things that you (client) used to do, or would like to do, but currently don’t?

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How would you (client) describe your spiritual or religious beliefs?

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Please place a check in front of any of the following that presently cause you difficulty:

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Required
Please place a check in front of any of the following that presently cause you difficulty: (part 2)
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Required
Please place a check in front of any of the following that presently cause you difficulty: (part 3)
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Required
Any other symptoms or issues not listed above? *
Occupational Data
If applicable, put N/A if not applicable.

What sort of work are you doing now?

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What sort of jobs have you held in the past?

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Does your present work satisfy you?  If not, what ways are you dissatisfied?

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Sex Information
If applicable, put N/A if not applicable.

Any relevant details regarding your first or subsequent sexual experiences?

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Is your present sex life satisfactory? If not, please explain: 

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Have you ever experienced any sexual abuse? (This could include fondling, inappropriate remarks, witnessing adults display sexual behavior, lack of privacy in home, coercion by adults to participate in sexual games, being “checked out” by parents to see if you are developing “properly” or having sex, intrusive touching etc): ___ If yes, please state the circumstances and people involved:

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If yes please state what you did about it: *
Family Data
Marital Status:
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Spouse/Partner's Name (N/A if N/A):
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Partner's Date of Birth:
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MM
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DD
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YYYY
Partner’s Occupation:
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Length of relationship:
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How satisfied are you with this relationship?
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Not very satisfied
Very satisfied

Any previous marriages? If so, please list dates and names of spouses.

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Do you have any children? Please list everyone residing in the home: *
Please list names and ages of any children biological:
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Please list names and ages of any children adopted:
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Please list names and ages of any step-children or other children:
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Please explain if parents are married/share custody or if there is a custody agreement.
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Has there been any verbal violence or abuse in your family? If so, please explain:

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What kind of discipline style is used in the home? *

Father

Living or deceased?  If deceased, your age at the time of his death: __ Cause of death? __ If alive, father’s present age?__ Occupation: _ Health:

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Mother

Living or deceased?  If deceased, your age at the time of her death: __ Cause of death? __ If alive, mother’s present age?__ Occupation: __ Health:

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Siblings

Number of brothers:_ Ages:  

Number of sisters:_Ages: 

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Relationship with brothers and sisters:

Past: 

Present:

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Give description of your father’s personality with his attitude toward you (past and present):

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Give description of your mother’s personality with her attitude toward you (past and present):

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In what ways were you punished by your parents as a child?

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Give an impression of your home atmosphere (i.e the home in which you grew up. Mention state of compatibility between parents and between parents and children):

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Were you able to confide in your parents? _ Did your parents understand you? _
Basically, did you feel loved and respected by your parents? 

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If you have a step parent, give your age when your parents divorced & when they remarried:

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Give an outline of your religious training:

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If you were not brought up by your parents, who did bring you up, and between what years?

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Who are the most important people in your life?

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Does any member of your family suffer from alcoholism, epilepsy, or anything which can be considered a “mental disorder”? 

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What was your greatest challenge or difficulty growing up in your family? 

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Goals for Treatment

List the benefits you hope to derive from this therapy: 

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List any situations which make you feel calm or relaxed:

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Please add any information not tapped by this questionnaire that may aid me in understanding and helping you:

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Referral/Modality

Did someone refer you? If yes, who?

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If you were not referred by someone, how did you find my practice?

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Which modalities are you most interested in? (For more information please see www.OceansideFamilyTherapy.com) *
Required

Is there anything else you think would be important for me to know about you or your family?

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