CITTA SUKHA Individual Client Intake Form
Client Questionnaire & Record
Personal Information
Please note: Information provided on this form and in session are protected as fully confidential information.

Email *
Date *
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Name *
Parent/Legal Guardian (if under 18) *
Address *
Mobile *
Email *
DOB *
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Age *
Gender *
Marital Status *
Referred by (if any) *
Have you previously received any type of emotional or mental health services (psychotherapy, psychiatric or counseling services, etc.)? *
If yes, previous therapy/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? *
Please list any specific health problems you are currently experiencing: *
How would you rate your current sleeping habits? *
Please list any specific sleep problems you are currently experiencing: *
How many times per week do you engage in physical activity or 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,which and for approximately how long? *
Are you currently experiencing anxiety, panic attacks or have any phobias? *
If yes, state which and when did you begin experiencing this? *
Are you currently experiencing any chronic pain? *
If yes, please describe: *
Do you drink alcohol more than once a week? *
Do you engage in recreational drug use? *
What significant life changes or stressful events have you experienced recently? *
In the section below, identify if there is a family history of any of the following. *
Yes
No
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
If yes, please indicate the family member’s relationship to you (e.g. father, grandmother, uncle, etc.). *
Do you consider yourself to be spiritual or religious? *
If yes, describe your faith or belief: *
What area of your life/relationships would you like to improve? *
What would you like to accomplish out of your time in therapy? *
Declaration and Waiver of Liability :
All the information I have provided is correct and complete.
I am responsible for my own health, including, but not limited to mental or physical illness, medication etc, during the sessions, and resulting from my participation.
I also relieve the therapist from all liabilities in the event of any loss, damages, injury or illness incurred while visiting the space of practice and participating in therapy.

I have read and agreed to abide by the above conditions. (Please provide Name & Signature) *
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