Client Intake Form

GENERAL PHYSICAL AND MENTAL HEALTH INFORMATION

1. Previously mental health services (psychotherapy, psychiatric, etc.): __Yes__No

Please explain: ______

______

______

2. Are you currently prescribed or taking any prescription medication(s)? __Yes__No Describe use: ______

______

Please list all current medications and dosages

Medication name / Dosage / Prescribing Doc / Reason for Medication / Start Date

3. Have you ever been prescribed/taken any psychiatric medication(s)? __Yes__No

Describe: ______

______

Please list all current medications and dosages

Medication name / Dosage / Prescribing Doc / Reason for Medication / Start Date

4. Please list current and past health problems, major operations and hospitalizations:

Current / Past

5. Race/Ethnicity: ______

Is this an issue? ______Desire to discuss in Therapy? ______

6. How would you rate your current physical health? (circle and explain)

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems you are currently experiencing: ______

______

______

7. How would you rate your current sleeping habits? (circle and explain)

Poor Unsatisfactory Satisfactory Good Very good

Please list specific sleep problems you are currently experiencing: ______

______

8. How many times per week do you exercise? ______

Describe types and amounts: ______

______

9. Describe your appetite/eating patterns (normal, problematic, healthy, unhealthy, etc.): ______

______

10. Are you currently experiencing sadness, grief or depression?__Yes__No

If yes, please explain: ______

______

______

11. Are you currently experiencing anxiety, panic attacks or any phobias?__Yes __No

If yes, please explain:______

______

12. Are you currently experiencing any chronic pain?__Yes__No

If yes, please explain:______

______

13. Explain your alcohol use:__Yes__No

If yes, please explain: ______

______

14. Explain your recreational drug use: __Daily __Weekly __Monthly __Rarely __Never

______

Please indicate current and past substance use:

Substance / Type / Amount used / How often? / How Long?
Tobacco
Alcohol
Prescription medications
Marijuana
Drugs (Heroine/LSD/PCP)
Other (please list):

15. Currently romantic relationship: __Yes__NoLength of Time: ______

If yes, please describe: ______

______

On a scale of 1-10, how satisfied are you with your relationship? ______

What do you like/dislike about your relationship? ______

______

16. What significant life changes have you experienced lately? ______

______

17. What stressors have you experienced recently? ______

______

FAMILY MENTAL HEALTH HISTORY

Check any past or impending issues that apply to you, your parents and/or siblings?

Specify: S=Self P=Partner M=Mother F=Father I=Sibling(s) E=Extended

IssueYes/NoFamily Member

Alcohol abuseYes/No______

Drug abuseYes/No______

Emotional problemsYes/No______

Psychiatric hospitalizationsYes/No______

AnxietyYes/No______

DepressionYes/No______

BipolarYes/No______

Other mental illnessYes/No______

UlcersYes/No______

AsthmaYes/No______

Serious physical illnessYes/No______

Weight/eating problemsYes/No______

Eating DisorderYes/No______

Sleeping problems/insomniaYes/No______

Suicide Attempted/completedYes/No______

Emotional/mental abuseYes/No______

Physical abuseYes/No______

Sexual abuseYes/No______

Domestic violenceYes/No______

Debilitating injuries/disabilitiesYes/No______

Numerous childhood illnessesYes/No______

Frequent relocationsYes/No______

Learning problemsYes/No______

DeathsYes/No______

DivorceYes/No______

Financial problemsYes/No______

Crisis/unemploymentYes/No______

Legal problemsYes/No______

Other ______Yes/no______

CURRENT AND PAST PROBLEMS AND/OR AREAS OF CONCERN

Now or Past scale: 1=Never, 2=Rarely, 3=Sometimes, 4=Often, 5=Always

Please place the number corresponding to the level of concern for each.

Problem or Concern areaShort DescriptionNowPast

Difficulty falling or staying asleep ______

Sleeping too much ______

Change in appetite, weight loss, or weight gain ______

Frequent crying ______

Panic attacks or anxiety attacks ______

Thoughts of killing or hurting myself ______

Attempts to kill or hurt myself ______

Problems concentrating ______

Problems remembering things ______

Periods of daily sadness lasting more than two weeks ______

I startle easily ______

Can’t stop remembering upsetting past events ______

Difficulty controlling my temper ______

I physically hurt other people ______

I break things ______

I worry a lot ______

Little or no interest in sex ______

I feel tired almost every day ______

Feelings of unreality ______

Made myself throw up in order to lose weight ______

Use(d) laxatives or exercise(d) excessively to lose weight ______

I feel like I am an outsider ______

Sexual problems ______

Worry that something is wrong with my body ______

Arguments with the people I live with ______

I hear voices inside my head ______

Other (please list): ______

______

SEVERITY OF SYMPTOMS/AREAS OF CONCERN

Rate the severity of the following symptoms according to the following rating scale:

0-No difficulty1-Mild2-Moderate3-Severe

_____ Decreased appetite_____ Nightmares

_____ Increased appetite/eating more_____ Hyper-vigilance

_____ Bingeing and/or purging_____ Obsessive thoughts

_____ Weight gain/loss: +/- _____ lbs._____ Compulsions

_____ Depressed mood_____ Spending sprees

_____ Decreased energy/fatigue_____ Racing thoughts

_____ Sleep changes: trouble falling asleep;_____ Rapid heart beat

staying asleep;waking up_____ Trouble breathing

Avg. # hours sleep ______Sweating

_____ Decreased sexual desire_____ Phobia

_____ Difficulty with sexual functioning_____ Police/Probation involvement

_____ Loss of interest in activities_____ Stealing

_____ Crying _____ Lying

_____ Feelings of hopelessness_____ Truancy

_____ Feelings of helplessness_____ Violent behavior towardsothers

_____ Decreased attention span_____Self-deprecation

_____ Inattentive/Distractible_____ Destruction of property

_____ Memory problems: Long/short-term_____ Harming animals

_____ Oppositional/Defiant_____ Fire setting

_____ Self-injurious behavior_____ Foul Language

_____ Thoughts of suicide_____ Anger outbursts

_____ Thoughts of harming others_____ Irritability

_____ Impulsivity_____Poor self-esteem

_____ Hyperactivity_____ Parenting Issues

_____ Anxiety/Nervousness_____ Feeling Guilty

_____ Worry/Fear_____ Stuffing Feelings

_____ Flashbacks of traumatic event_____ Self Loathing

_____Work Stress_____ Other ______

_____School Stress_____ Other ______

_____Relationship Stress_____ Other ______

ADDITIONAL INFORMATION AND GOALS FOR THERAPY

1. Currently employment:__Yes__No

If yes, please describe (time and duties): ______

______

What do you enjoy about your work? ______

______

Current stressors about your work: ______

______

______

2. Do you consider yourself to be spiritual or religious? __Yes__No

If yes, please describe: ______

______

Would you like this to be discussed in sessions? __Yes__No

3. Current education level and areas of study: ______

______

4. Hobbies and interests: ______

5. Likes: ______

______

6. Dislikes: ______

______

7. Hopes/dreams: ______

______

______

8. Personal strength(s): ______

______

______

______

9. Growth area(s): ______

______

______

10. Why are you coming to therapy NOW? ______

______

______

11. Goals for therapy (Specific & measurable): ______

______

______

______

12. Support network: ______

______

13. Coping skills/mechanisms: ______

______

14. How will you know when you are finished with therapy? ______

______

15. How long do you expect therapy to last? ______

Terrace Counseling, LLC Updated 05132014

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