Client Intake Form Name * First Name Last Name Name of Parent/Guradian (If under 18 years) First Name Last Name Birth Date * MM DD YYYY Marital Status Never Married Domestic Partnership Married Separated Divorced Widowed Please list the names and ages of any children: Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### May we leave a message on your cell phone voicemail? Yes No Email Address: * *Please note: Email correspondence is not considered to be a confidential medium of communication. May we email you? Yes No Referred by (if any): Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.) ? No Yes If yes, kindly state the name of previous therapist/practitioner Are you currently taking any prescription medication? No Yes If yes, please list Have you ever been prescribed psychiatric medication? No Yes If yes, please list and provide dates GENERAL HEALTH AND MENTAL HEALTH INFORMATION 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 to you participate in? Please list any difficulties you experience with your appetite or eating patterns: Are you currently experiencing overwhelming sadness, grief or depression? No Yes If yes, please indicate for how long: Are you currently experiencing anxiety, panic attacks or have any phobias? No Yes If yes, when did you begin experiencing this? Are you currently experiencing any chronic pain? No Yes If yes, please describe Do you drink alcohol more than once a week? No Yes How often do you engage recreational drug use? Daily Weekly Monthly Infrequently Never Are you currently in a romantic relationship? No Yes If yes, for how long? On a scale of (worst) 1-10 (best) , how would you rate your relationship? 1 2 3 4 5 6 7 8 9 10 What significant life changes or stressful events have you experienced recently? FAMILY MENTAL HEALTH HISTORY Please check if there is a family history of any of the following: Alcohol/Substance Abuse Anxiety Depression Domestic Violence Eating Disorders Obesity Obsessive Compulsive Behavior Schizophrenia Suicide Attempts If you answered yes to any of the above, please indicate which option and the family member’s relationship to you in the space provided (father, grandmother, uncle, etc): ADDITIONAL INFORMATION: Are you currently employed? No Yes 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? No Yes If yes, please 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? Thank you!
