Welcome‎ > ‎Private Practice‎ > ‎

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: □ Male □ Female
Marital Status:
□ Never Married □ Domestic Partnership □ Married □ Separated
□ Divorced □ Widowed
 
Please list any children/age: _________________________________________________
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 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 out of your time in therapy?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Comments