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Client Intake Questionnaire
Please fill in the information below. We will follow up to schedule a consultation with you.
Please note: information provided on this form is protected as confidential information.
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Email
*
Your email
Personal Information
Full Name
*
Your answer
Parent or Guardian Name (if under 18)
Your answer
Address
*
Your answer
Home Phone (may we leave a message?)
Your answer
Cell/Work/Other Phone: (may we leave a message?)
Your answer
D.O.B.
*
MM
/
DD
/
YYYY
Age
*
Your answer
Gender
Female
Male
Prefer not to say
Other:
Clear selection
Martial Status
Never Married
Separated
Domestic Partnership
Divorced
Married
Widowed
Other:
Clear selection
Referred By (if any)
Your answer
History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Yes
No
Clear selection
If you said yes to the previous question, who was your previous therapist/practitioner?
Your answer
Are you currently taking any prescription medication? If yes, please list:
Your answer
Have you ever been prescribed psychiatric medication? If yes, please list and provide dates:
Your answer
General and Mental Health Information
1. How would you rate your current physical health?
Poor
1
2
3
4
5
Very Good
Clear selection
2. How would you rate your current sleeping habits?
Poor
1
2
3
4
5
Very Good
Clear selection
Please list any specific sleep problems you are currently experiencing:
Your answer
How many times per week do you generally exercise?
Your answer
What types of exercise do you participate in?
Your answer
Please list any difficulties you experience with your appetite or eating problems:
Your answer
Are you currently experiencing overwhelming sadness, grief or depression? If yes, for approximately how long?
Your answer
Are you currently experiencing anxiety, panics attacks or have any phobias? If yes, when did you begin experiencing this?
Your answer
Are you currently experiencing any chronic pain? If yes, please describe:
Your answer
Do you drink alcohol more than once a week?
Yes
No
Clear selection
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?
Your answer
On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
Poor
1
2
3
4
5
6
7
8
9
10
Exceptional
Clear selection
What significant life changes or stressful events have you experienced recently?
Your answer
Family Mental Health History
In the section below, identify if there is a family history of any of the following.
Please select all that apply
Yes
No
Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts
Yes
No
Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts
Please indicate here the family member’s relationship next to the conditions stated above (e.g. father, grandmother, uncle, etc.)
Your answer
Additional Information
1. Are you currently employed?
Yes
No
Clear selection
If yes, what is your current employment situation?
Your answer
Do you enjoy your work? Is there anything stressful about your current work?
Your answer
Do you consider yourself to be spiritual or religious? If yes, describe your faith or belief:
Your answer
What do you consider to be some of your strengths?
Your answer
What do you consider to be some of your weaknesses?
Your answer
What would you like to accomplish out of your time in therapy?
Your answer
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