Life Works Counseling Client Intake Form

Adult Client Questionnaire

The information you provide will help in the planning of your counseling and assist you and your psychologist to clarify your therapy goals.

Pleaseprovidethefollowinginformationforourrecords.Leaveblankanyquestionyouwould rather notanswer.Informationyouprovidehereisheldto the samestandardsofconfidentiality as ourtherapy..

Name:

(Last)(First)(MiddleInitial)

Birth Date: //Age: Gender: □Male □Female

MaritalStatus: □NeverMarried □Partnered □Married □Separated □Divorced □Widowed

NumberofChildren:

Address:

HomePhone: Maywe leavea message? □Yes □No

Mobile/OtherPhone: Maywe leavea message? □Yes□No

E-mail:

*Pleasebeawarethatemailmightnotbe confidential

Maywe emailyou? □Yes □No

Emergency contact: Phone number:

Are youcurrentlyreceivingpsychiatricservices, professionalcounselingorpsychotherapy elsewhere?

□No □ Yes Where?

Haveyouhad previouspsychotherapy?

□No □ Yes,at(Previous therapist’s name)

Are youcurrentlytakingprescribedpsychiatricmedication(antidepressantsorothers)?

□Yes □ No If Yes,pleaselist:

Ifno,haveyoubeenpreviouslyprescribedpsychiatricmedication?

□Yes □ No If Yes,pleaselist:

Referredby:

HEALTHANDSOCIAL INFORMATION

1.Howisyourphysical healthatpresent?

□Poor□Unsatisfactory□Satisfactory□Good □Verygood

2.Pleaselistanypersistentphysical symptomsorhealthconcerns(e.g. chronicpain, headaches,hypertension,diabetes,etc.):

3.Areyouhavinganyproblemswithyoursleephabits? □No□Yes

Ifyes,checkwhereapplicable:

□ Sleepingtoolittle □Sleepingtoomuch □Poorqualitysleep □Disturbingdreams

□Other

4.Howmanytimes per weekdoyouexercise? Approximatelyhowlongeachtime?

5.Areyouhavinganydifficultywithappetiteoreatinghabits? □No□Yes

Ifyes,checkwhereapplicable: □Eatingless □Eatingmore □Binging □Restricting

Haveyouexperiencedsignificantweightchangein thelast2months? □No □Yes

6.Doyouregularlyuse alcohol? □No □Yes

Inatypicalmonth, howoftendoyouhave4ormoredrinks ina24-hourperiod?

7.Howoften doyouengageinrecreationaldruguse?

□Daily□Weekly□Monthly□Rarely□Never

8.Haveyouhad suicidalthoughtsrecently? □ Frequently □ Sometimes □Rarely □Never

Haveyouhad themin thepast? □Frequently □Sometimes □Rarely □Never

9.Areyoucurrentlyina romanticrelationship? □No□Yes

Ifyes, howlonghaveyoubeeninthisrelationship?

Onascaleof1-10, howwouldyouratethequalityofyourcurrentrelationship?

10.Inthelastyear,list any significantlifechangesorstressors you have experienced:

Haveyoueverexperienced:

Extremedepressedmood: □No □Yes

Wild MoodSwings: □No □Yes

RapidSpeech: □No □Yes

ExtremeAnxiety: □No □Yes

PanicAttacks: □No □Yes

Phobias: □No □Yes

Sleep Disturbances: □No □Yes

Hallucinations: □No □Yes

Unexplainedlossesoftime: □No □Yes

Unexplainedmemorylapses: □No □Yes

Alcohol/SubstanceAbuse: □No □Yes

FrequentBody Complaints: □No □Yes

EatingDisorder: □No □Yes

Body ImageProblems: □No □Yes

RepetitiveThoughts(e.g., Obsessions): □No□Yes

RepetitiveBehaviors(e.g.,FrequentChecking,Hand-Washing): □No □Yes

HomicidalThoughts: □No □Yes

SuicideAttempt: □No □Yes

OCCUPATIONALINFORMATION:

Are youcurrentlyemployed? □No□Yes

Ifyes, whois yourcurrentemployer/position?

Ifyes, areyouhappyatyourcurrentposition?

Pleaselistanywork-related stressors,ifany:

RELIGIOUS/SPIRITUALINFORMATION:

Doyouconsider yourselftobereligious? □No□Yes

Ifyes, whatis yourfaith?

Ifno,doyouconsider yourselftobespiritual? □No□Yes

FAMILYMENTALHEALTHHISTORY:

Has anyoneinyourfamily(eitherimmediatefamilymembersorrelatives)experienced difficultieswiththefollowing?(Check any that applyand listfamilymember,e.g., Sibling,Parent,Uncle,etc.):

DifficultyFamilyMember

Depression: □No □Yes

BipolarDisorder: □No □Yes

AnxietyDisorders: □No□Yes

PanicAttacks: □No □Yes

Schizophrenia: □No □Yes

Alcohol/SubstanceAbuse: □No□Yes

EatingDisorders: □No□Yes

LearningDisabilities: □No □Yes

TraumaHistory: □No □Yes

SuicideAttempts: □No□Yes

OTHERINFORMATION:

Whatdoyouconsidertobeyourstrengths?

Whatcopingstrategiesdo you use?

Briefly describe the problem you would like help with right now

Is there anything else you would like your psychologist to know?

ABOUT YOUR CONCERNS

Please check all the items below that you currently experience or having difficulty, and feel free to add any others at the bottom under “Other concerns or issues.” You may add details as needed to clarify.

□ Abortion / □Employment problems / □Low frustration tolerance / □Self abuse - other
□ Abuse - emotional / □Employment - termination / □Low income / □Self abuse - scratching
□ Abuse - neglect / □Emptiness / □Low mood / □Self abuse – pulling hair out
□ Abuse - sexual / □Exhaustion / □Marital conflict / □Self-centeredness
□ Adoption / □Failure / □Marital distance / □Self-control
□ Aggression / □Fatigue, low energy / □Marital infidelity/affairs / □Self-esteem
□ Alcohol Use / □Fears, phobia / □Medical concerns / □Self-neglect, poor self-care
□ Ambition / □Feelings of helplessness/hopeless / □Memory problems / □Separation
□ Anger / □Financial troubles / □Menopause / □Sexual addiction
□ Anxiety / □Friendship problems / □Menstrual problems / □Sexual conflicts
□ Arguing / □Gambling / □Mixed feelings / □Sexual desire differences
□Attention problems / □Gender identity / □Mood swings / □Shyness
□Career concerns / □Goals not being met / □Motivation / □Smoking
□Childhood issues / □Grieving, mourning / □Mourning / □Spirituality
□Children – care of / □Guilt / □Nail-biting / □Step-parenting
□Children - custody / □Headaches, pains / □Nervousness / □Stress
□Children - management / □Health, illness / □Nightmares / □Stress-management
□Choices I’ve made / □Hearing voices / □Obsessions, compulsions / □Suspiciousness
□Chronic pain / □Hostility / □Outbursts / □Temper problems
□Codependence / □Hyperactivity / □Oversensitive to criticism / □Tension / stress
□Communication / □Impulsive spending / □Oversensitive to rejection / □Thought disorganization
□Compulsive spending / □Impulsiveness / □Overweight / □Threats of violence
□Confusion / □Incest / □Panic or anxiety attacks / □Tiredness
□Constant conflicts / □Indecision / □Parenting / □Tobacco use
□Crying / □Inferiority feelings / □Perfectionism / □Unhappiness
□Deaths / □Infertility / □Pessimism / □Violence
□Debt / □Inhibitions / □Phobias / □Violence – victim of crime
□Decision making / □Interpersonal conflicts / □Physical problems / □Weight and diet issues
□Dependence / □Irresponsibility / □PMS / □Withdrawal - isolating
□Depression / □Irritability / □Poor self-care / □Work problems
□Distractibility / □Judgment problems / □Pornography use / □Worry all the time
□Divorce, separation / □Laziness / □Procrastination / □Other concerns or issues:
□Domestic violence / □Legal matters, charges, suits / □Relationship problems
□Drug abuse – over the counter / □Loneliness / □Relaxation
□Drug abuse - prescription / □Loss of control / □Re-marriage
□Drug abuse – street drugs / □Risk-taking
□Drug abuse - alcohol / □Losses / □Sadness
□Education / □Loss of interest in activities / □School problems
□Employment – lack of / □Loss of interest in sex / □Self abuse - burning
□Employment - overdoing / □Low energy / □Self abuse - cutting

How did you firsthear about us?

☐ Referring Doctor ☐Search engine ☐Health professional (who? ______)☐ School ☐ Brochure ☐ Facebook (what page? ______)

☐ Other (please specify) ______

Thank you for completing this form

Please save it to your computer and attach it to an email to

This will allow your psychologist to read the information prior to your appointment.

Otherwise, please print and bring to your first appointment.