Manakai O Malama Psychotherapy Pre-Appointment Questionnaire
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Name
Age
DOB
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Today's Date
MM
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Briefly describe your reason(s) for seeking therapy at this time:
Is this appointment related to:
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What goals do you wish to accomplish during the therapy process?
Are you currently seeing another therapist?
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If yes, please indicate the therapist's name:
Regarding previous counseling experience: list the therapist(s), location(s), Date(s), and reason(s) for therapy.
Have you ever attempted or very seriously contemplated suicide?
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If yes, describe briefly and indicate date(s):
Have you ever been neglected or emotionally, physically, or sexually assaulted or abused?
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Have you ever been verbally or physically assaultive towards others?
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In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past MONTH, you:
1. Have had nightmares about it or thought about it when you did not want to?
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2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?                        
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3. Were constantly on guard, watchful, or easily startled?                                                                                            
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4. Felt numb or detached from others, activities, or your surroundings?                                                                      
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Have you ever had a psychiatric hospitalization?
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If yes, describe briefly and indicate date(s):
Are you under the care of a psychiatrist?
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If yes, psychiatrist name:
How would you rate your current financial stress?        
None
Worst
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Do you have any housing concerns?
If yes, please describe:
Medications
List all medications you are currently taking: include Medication, dosage, treating, and whether taking according to prescription.
Please respond if you have one of the following conditions:
High cholesterol
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If yes, problems with medication(s)
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Diabetes
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If yes, most recent home glucose readings:
If yes, problems with medication(s)
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High Blood Pressure
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If yes, most recent home blood pressure readings:
If yes, problems with medication(s)?
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Please list any other chronic illness, disabilities, or medical conditions that you have been diagnosed with:
Condition #1
Problems with medication(s)?
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Condition #2
Problems with medication(s)?
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Condition #3
Problems with medication(s)?
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Alcohol
How often do you have a drink containing alcohol?
How often do you have six or more drinks on one occasion?
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Do you think you have a drinking problem?
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Does anyone else think you have a drinking problem?
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Have you in the past or currently abused illegal drugs?
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If yes, please briefly explain
Smoking
Do you use nicotine?
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If yes, how often? How much?
Caffeine
Do you consume any caffeine?
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If yes, how often? How much?
Diet
How would you rank your current overall diet on a scale from 1 – 10?
Poor
Excellent
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Sleep
Average number of hours you sleep at night:
How would you rank your overall sleep at the present time on a scale from 1 – 10?
Poor
Excellent
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Do you have any problems with sleep?    
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If yes, how often?
If yes, do you wake up in the night?
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If yes, how often and how long does it take you to fall asleep?
Exercise
Do you exercise?
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If yes, how often? How long?
If yes, please briefly describe types of activity:
Birth control
Do you use any form of birth control?
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If yes, what method?
Is there anything you would like to work on to improve your health?
Education
Highest level of education completed:
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If you received a college/graduate degree or completed trade school, what did you study?  If you are currently a student, what are you studying?
Are you employed?
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If yes, average hours worked per week:
If yes, what is your occupation?
Are you satisfied with your occupation?
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With what culture(s), ethnicity(ies), &/or race(s) do you most strongly identify?
How would you briefly describe your spiritual beliefs?
Have you had any legal problems?
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If yes, please briefly describe:
Do you feel you have adequate social support/meaningful friendships?
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Relationship status (check all that apply):
If other, please describe
Sexual orientation:
Gender identification:
Preferred pronoun:
If currently in a relationship, partner name & gender identification:
Length of relationship:
How satisfied are you with your current relationship on a scale from 1 – 10?
poor
excellent
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If you have children (biological, adopted, foster, step, and other), please indicate:
Name 1
Age 1
Lives at home?
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Name 2
Age 2
Lives at home?
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Name 3
Age 3
Lives at home?
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Name 4
Age 4
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Lives at home?
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For your biological parents, grandparents, & siblings, if known please indicate:
(Maternal Grandmother) - name, age, please list any current or past PSYCHIATRIC diagnoses:
(Maternal Grandfather) - name, age, please list any current or past PSYCHIATRIC diagnoses:
(Paternal Grandmother) - name, age, please list any current or past PSYCHIATRIC diagnoses:
(Paternal grandfather) - name, age, please list any current or past PSYCHIATRIC diagnoses:
(Mother) - name, age, please list any current or past PSYCHIATRIC diagnoses:
(Father) - name, age, please list any current or past PSYCHIATRIC diagnoses:
(Sibling) - name, age, please list any current or past PSYCHIATRIC diagnoses:
(Sibling 2) - name, age, please list any current or past PSYCHIATRIC diagnoses:
(Other) - name, age, please list any current or past PSYCHIATRIC diagnoses:
If you have previously been married, please fill out the following section:
Date began
MM
/
DD
/
YYYY
Date ended
MM
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DD
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YYYY
Ex-spouse first name
Children
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Date began
MM
/
DD
/
YYYY
Date ended
MM
/
DD
/
YYYY
Ex-spouse first name
children
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Date began
MM
/
DD
/
YYYY
Date ended
MM
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DD
/
YYYY
Ex-spouse frist name
Children
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Is there anything else you think it is important for your therapist to know about you &/or your family?
PHQ-9 & GAD-7
Over the LAST 2 WEEKS on how many days have you
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or over eating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead or of hurting yourself in some way.
Over the LAST 2 WEEKS on how many days have you
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
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