Client Intake
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Client First Name
Client Last Name
Address: Number, Street, City, State, Zip Code
Date of Birth
MM
/
DD
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I acknowledge that I have received a copy of the Notice of Privacy Practices of Chris J. Gonzalez, Ph.D., LMFT. I have been given the opportunity to read this notice and I understand that this notice describes how medical information about me may be used and disclosed and how I can get access to this information.   *
Primary Phone Number
Other Phone Number
Email address
Biological Sex
Race / Ethnicity
Sexual Orientation
Relationship Status
Highest Level of Education
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Religion and Spirituality
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How important is your religion and spirituality to you?
Unimportant
Very Important
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How did you hear about Dr. Gonzalez?
List three Emergency Contacts: Name, Address, Phone Number
Employer
Position at work
Employment start date
MM
/
DD
/
YYYY
Annual Household Income Range
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Names, ages, and relationship to you of all people in your household
Name and Phone number of Medical Doctor
Name and Phone Number of your Psychiatrist
Name and Phone Number of most recent Therapist
Please list all medical and mental health conditions you have or have had previously (e.g. diabetes, depression etc)
Please list all medications you are taking AND what they are prescribed to treat
How often do you exercise?
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For how long do you usually exercise?
How many hours of sleep do you usually get in a 24 hours period?
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How is your sleep quality?
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What are your eating habits?
Cigarette Smoking
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Vaping
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What is the content you vape?
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How frequently do you consume at least one drink of alcohol? (1 Drink = 12 oz beer, 8-9 oz Malt Liquor, 5 oz wine, 2-3 oz Liqueur, 1,5 oz hard liquor
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How many drinks containing alcohol do you have in a day when you drink?
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How often do you have 6 or more drinks?
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Have you ever felt like you need to cut down on your drinking?
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Have people annoyed your by criticizing your drinking?
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Have you ever felt bad or guilty about your drinking?
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Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
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How frequently do you use drugs? (i.e. other than those prescribed by a doctor)
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Please list any drugs you have used in the past 6 months
Currently, how often have you had suicidal thoughts?
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In the past, how often have you had suicidal thoughts?
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Have you ever experienced any of the following?
Yes
No
Depressed mood
Serious mood swings
Neurological issues (e.g. stroke)
Anxiety
Panic Attack
Phobia
Sexual issues
Sleep disturbance
Hallucinations
Unexplained loss of time
Unexplained memory lapse
Frequent body complaints
Eating disorder
Repetitive thoughts
Repetitive behavior
Homicidal thoughts
Thoughts of death
Thoughts of self-harm
Thoughts of harming others
Other
When therapy is completed, what will be different?
List 3 things that will be better that indicate therapy is no longer needed.
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