Shannon McFarlin, MA, LMFT
Psychotherapy Intake Form
First and last name
Your answer
Date of birth
Your answer
Age
Your answer
Gender identity
Sexual orientation
Mailing address
Your answer
Phone number
Your answer
Email address
Your answer
Preferred method of contact
Occupation and employer
Your answer
How did you hear about me?
Have you had any psychiatric hospitalizations?
If yes, please describe
Your answer
Have you or do you think about suicide?
Have you or do you think about harming others?
Where were you born and raised?
Your answer
Are your parents still together?
Names and ages of siblings
Your answer
Please describe your childhood
Your answer
What were some of your family's core values?
Your answer
Please describe your relationship with your family now
Your answer
Is there a family history of substance abuse?
Is there a family history of emotional or physical abuse?
Is there a family history of sexual abuse?
Your family's religious affiliation, if any
Your answer
Please describe your eating, sleeping, and exercise habits
Your answer
Please describe any stressful events going on in your life
Your answer
Describe your support system
Your answer
Have you been to therapy before?
If yes, please describe what worked and what didn't work for you in terms of style of therapy
Your answer
What would you like to work on in therapy now?
Your answer
Relationship status
Names and ages of children
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service