Intake Form
Email address *
To help us better understand and serve you, please answer the following questions as openly and honestly as possible. Please know the information you share on this form is held in confidence and will only be reviewed by those who will be working with you on the SentWell team. We recognize that this information is yours and not ours, and therefore will not share any part of this information without your express permission.
Personal Information
1. Your Name: *
Your answer
2. Date of Birth: *
Your answer
3. Your Passport Country *
Your answer
4. Email Address: *
Your answer
5. Mobile Phone: *
Your answer
6. Home Phone: *
Your answer
7. Address: *
Your answer
8. Your Spouse's Name:
Your answer
9. Spouse's Date of Birth:
Your answer
10. Spouse's Passport Country:
Your answer
11. Spouse's Email Address:
Your answer
12. Spouse's Mobile Phone:
Your answer
Family History
13. What was your father's occupation? Describe him: *
Your answer
14. What was your mother's occupation? Describe her: *
Your answer
15. How would you describe their relationship? *
Your answer
16. Who raised you and with whom did you grow up? *
Your answer
17. How many brothers or sisters do you have (older, younger)? *
Any step- or half-siblings?
Your answer
18. Describe your home life growing up. What was the emotional climate? *
Your answer
19. Is there a history of mental illness or drugs/alcohol problems in your family (please explain)? *
Your answer
Personal History
20. Describe any problems you had in school (academic, discipline, problems making friends, etc): *
Your answer
21. What were the most formative events during your school years? *
Your answer
22. Describe any problems you had on the job: *
Were you ever fired from a position? If yes, please explain.
Your answer
23. Describe any legal problems you have had: *
Your answer
24. Have you ever experienced any physical or sexual abuse? *
If so, by whom, at what age, andfor how long?
Your answer
25. Did you have any other traumatic experiences (illness, accident, witness violence)? *
Your answer
26. When would you say you felt the best physically/emotionally? *
Your answer
27. When would you say you felt the worst physically/emotionally? *
Your answer
28. Have you ever seen a counselor or therapist? If so, what was it for, how long did you see them and what was the outcome? What kind of counselor/therapist? (Pastoral, MFT, Psychologist, biblical counselor, etc.) *
Your answer
29. Please list any medications you are currently taking and what they are for: *
Your answer
30. Have you ever used illegal drugs or alcohol? *
If so, which ones and for how long?
Your answer
31. Have you ever had any problems with pornography? *
If so, please describe:
Your answer
32. Have you ever had any problems with eating disorders? *
If so, please describe:
Your answer
Current Status
33. What is your current role? *
Your answer
34. Who is your current supervisor? *
Your answer
35. What is their contact information (mobile, email, etc.)? *
We always encourage involving your supervisor in your care. If this is a problem, please indicate below
Your answer
36. Are you currently involved in any legal proceedings (charges, custody, etc.)? *
Your answer
37. Name three of your primary supports, your relationship and how often you have contact with them: *
Your answer
38. Are you currently using any illegal drugs or alcohol? *
If so, how much and how often.
Your answer
39. What is your current living situation? *
Your answer
40. If you have children, list their names and ages.
Your answer
41. Please list any miscarriages or abortions you might have had and the dates. *
Your answer
42. Who are the most important people in your life now? *
Your answer
43. Select any of the following that apply to you in the last year: *
Required
Self Description
44. Please list the three worst experiences you have had in your life to date. *
Your answer
45. Please list the three best experiences you have had in your life to date. *
Your answer
46. What do you consider to be your main weaknesses? *
Your answer
47. What do you consider to be your main strengths? *
Your answer
48. What are your hobbies, what do you do for fun? *
Your answer
Concerns to be Addressed
49. Are you aware of any concerns or problems not mentioned in this questionnaire that would be important for your evaluator to know? *
Your answer
50. What would you say are the three greatest concerns for which you would like to receive care? *
Your answer
51. Explain as best you can how long have you been struggling with each of these concerns: *
Your answer
52. Please indicate how distressing your current problems are to you: *
No distress
Unbearable distress
53. What are your hopes for receiving care? *
Your answer
Thank you for your responses. Please notify your SentWell Staff that you have completed the questionnaire.
* Privacy Notice *
In compliance with the General Data Protection Regulation (EU) 2016/679, we are informing you that the data you provide in this form to the SentWell team will be treated with complete confidentiality. We will keep your data for the purposes as stated in this form until a time when we hear from you that you would like your data removed. We will not share nor sell your information to anyone. You can contact the Delegation of Data Control at: info@sentwell.org if you wish to alter, remove or limit your data. Thank you.
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