Client Intake Questionnaire

Please note: information provided on this form is protected as confidential information.

Personal Information

*Please note: Email correspondence is not considered to be a confidential medium of communication

Marital Status
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Are you currently taking any prescription medication? (If yes, please list)
Have you ever been prescribed psychiatric medication?
How would you rate your current physical health?
How would you rate your current sleeping habits?
Are you currently experiencing overwhelming sadness, grief, or depression?
Are you currently experiencing anxiety, panics attacks, or have any phobias?
Are you currently experiencing any chronic pain?
Do you drink alcohol more than once a week?
How often do you engage in recreational drug use?
Are you currently in a romantic relationship?
Family Mental Health History
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)
Alcohol/Substance Abuse
Domestic Violence
Eating Disorders
Obsessive Compulsive Behavior Schizophrenia
Suicide Attempts
Additional information
Are you currently employed?
Do you consider yourself to be spiritual or religious?