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Client Intake Questionnaire

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

Personal Information

Name

Email

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

Marital Status

Never Married Domestic Partner Married Separated Divorced Widowed

History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

Yes No

Are you currently taking any prescription medication? (If yes, please list)

Yes No

Have you ever been prescribed psychiatric medication?

Yes No

How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise do you participate in?

Please list any difficulties you experience with your appetite or eating problems:

Are you currently experiencing overwhelming sadness, grief, or depression?

Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panics attacks, or have any phobias?

Yes No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Yes No

If yes, please describe

Do you drink alcohol more than once a week?

Yes No

How often do you engage in recreational drug use?

Daily Weekly Monthly Infrequently Never

Are you currently in a romantic relationship?

Yes No

If yes, for how long?

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?

What significant life changes or stressful events have you experienced recently?

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

Yes No

List family member

Anxiety

Yes No

List family member

Depression

Yes No

List family member

Domestic Violence

Yes No

List family member

Eating Disorders

Yes No

List family member

Obesity

Yes No

List family member

Obsessive Compulsive Behavior Schizophrenia

Yes No

List family member

Suicide Attempts

Yes No

List family member

Additional information

Are you currently employed?

Yes No

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious?

Yes No

If yes, describe your faith or belief:

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy?

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