Intake Form

If possible, please fill out this form, print it and bring it with you to your first session.

Please provide the following information and answer the questions below. Please note

that information you provide is protected as confidential information.

Name: ______________________________________________________________

(Last) (First) (Middle Initial)

Name of parent/guardian (if under 18 years):

____________________________________________________________________

(Last) (First) (Middle Initial)

Birth Date: ______ /______ /______ Age: ________ Gender: ________________

Marital Status:

□ Never Married □ Domestic Partnership □ Married □ Separated

□ Divorced □ Widowed

Please list any children/ages: ____________________________________________

Address: ________________________________________________________________

(Street and Number)

________________________________________________________________________

(City) (State) (Zip)

Home Phone: May we leave a message? □Yes □No

Cell/Other Phone: May we leave a message? □Yes □No

*E-mail: _________________________________________ May we email you? □Yes □No

*(Please note that email correspondence is not considered to be a confidential medium of communication.)

Referred by (if any): _______________________________________________________

Have you previously received any type of mental health services (psychotherapy, psychiatric

services, etc.)?

□ No

□ Yes, previous therapist/practitioner: ________________________________________

Are you currently taking any prescription medication?

□ Yes

□ No

Please list: _______________________________________________________________

________________________________________________________________________

Have you ever been prescribed psychiatric medication?

□ Yes

□ No

Please list and provide dates: ______________________________________________

________________________________________________________________________

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

1. How would you rate your current physical health? (please circle)

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems you are currently experiencing:

________________________________________________________________________

2. How would you rate your current sleeping habits? (please circle)

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific sleep problems you are currently experiencing:

________________________________________________________________________

3. How many times per week do you generally exercise? ____________________

What types of exercise to you participate in: _______________________________

________________________________________________________________________

4. Please list any difficulties you experience with your appetite or eating patterns.

________________________________________________________________________

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

□ No

□ Yes

If yes, for approximately how long? _______________________________________

6. Are you currently experiencing anxiety, panic attacks or have any phobias?

□ No

□ Yes

If yes, when did you begin experiencing this? ______________________________

7. Are you currently experiencing any chronic pain?

□ No

□ Yes

If yes, please describe. ____________________________________________________

8. Do you drink alcohol more than once a week? □ No □ Yes

9. How often do you engage recreational drug use? □ Daily □ Weekly □ Monthly

□ Infrequently □ Never

10. Are you currently in a romantic relationship? □ No □ Yes

If yes, for how long? __________________

On a scale of 1-10, how would you rate your experience of fulfillment in this relationship? _________

11. 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 (father,

grandmother, uncle, etc.). Please circle and list family member.

Alcohol/Substance Abuse: yes/no ____________________

Anxiety: yes/no ____________________

Depression: yes/no ____________________

Domestic Violence: yes/no ____________________

Eating Disorders: yes/no ____________________

Obesity: yes/no ____________________

Obsessive Compulsive Behavior: yes/no ____________________

Schizophrenia: yes/no ____________________

Suicide Attempts: yes/no ____________________

ADDITIONAL INFORMATION

1. 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?

___________________________________________________________________________

2. Do you consider yourself to be spiritual or religious? □ No □ Yes

If yes, please describe your faith or belief or spiritual practice.

___________________________________________________________________________

3. What do you consider to be some of your strengths?

___________________________________________________________________________

4. What do you consider to be some of your weaknesses?

___________________________________________________________________________

5. What would you like to accomplish/focus on during your time in therapy?

___________________________________________________________________________

Name

___________________________________________________________________________

Date

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