Client Intake Questionnaire

Please fill in the information in the below form or click the button below to download, print, and bring it with you to your first session.
Please note: information provided on this form is protected as confidential information.

Download & Print

Name *

First

Last

Address:

Home Phone:

May we leave a message on your home phone?

Cell Phone:

May we leave a message on your cell phone?

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

May we leave a message on your email?

Date of Birth:

Age:

Gender:

Marital Status:

Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed

Referred By (if any):

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

If yes, previous therapist/practitioner:

Are you currently taking any prescription medication?

If yes, please list:

Have you ever been prescribed psychiatric medication?

If yes, please list and provide dates:

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?

If yes, for approximately how long?

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

If yes, for approximately how long have you experienced anxiety, panic attacks, or phobias?

Are you currently experiencing any chronic pain?

If yes, please describe:

Do you drink alcohol more than once a week?

How often do you engage in recreational drug use?

Daily
Weekly
Monthly
Infrequently
Never

Are you currently in a romantic relationship?

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

Choice 3

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

If yes, List Family Member for alcohol/substance abuse:

Anxiety

If yes, List Family Member for Anxiety:

Depression

If yes, List Family Member for Depression:

Domestic Violence

If yes, List Family Member for Domestic Violence:

Eating Disorders

If yes, List Family Member for Eating Disorders:

Obsessive Compulsive Behavior

If yes, List Family Member for Obsessive Compulsive Behavior:

Schizophrenia

If yes, List Family Member for Schizophrenia:

Suicide Attempts

If yes, List Family Member for Suicide Attempts:

Are you currently employed?

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?

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?