INTAKE FORM
Please fill out this form and bring it to your first session.
Name: ______DOB:______
(Last) (First)(Middle Initial)
Name you prefer to be called:______
Address:______
Phone Number:______Email:______
Is it all right to leave a message by Phone? Yes No By Text? Yes No Email: Yes No
Do you identify as ____Female_____Male_____M-F Trans____F-M Trans___Gender Non-Conforming______
Are you____Single_____Married____Divorced_____Co-habitating____Living with
Have you previously received any type of mental health services?
□ No
□ Yes, previous Therapist/practitioner and location, and reason seen: ______
When was your last physical exam?______
Please list medications and provide the name and address of the Physician who prescribes these: ______
______
How would you rate your current physical health? (please circle)
Poor Unsatisfactory Satisfactory Good Very good
Please list any health problems you are currently experiencing:
______
Have you ever had a Traumatic Brain Injury/Concussion/Loss of Consciousness?______When?______
Please list any hospitalizations, with dates, the reasons for this, and who treated you :
______
Do you have firearms in your home, or car?______If yes, how are they secured?______
How often do you wear your seatbelt?______
Do you smoke? If so, how much?______
Have you gained or lost more than 5 pounds in one month during the past year?______
How many times per week do you generally exercise? ______
What types of exercise do you do?______
How many times per week, if any, do you have trouble going to sleep, staying asleep, or
becoming awake before you intended to?______
What things do you enjoy doing:______
Please list any difficulties you experience with your appetite or eating patterns:
______
Do you drink alcohol more than once a week? __ No __ Yes How much, and what beverage? ______Do you binge drink?______
How often do you engage recreational drug use,if any? ___ Daily ___ Weekly
___ Monthly ___ infrequently ___ Never
Have you ever been arrested?______If yes, what was the charge, the outcome of the case, and the State where it occurred?______
Have you never been involved in a Civil Case? ______If yes, what for?______
______
Please circle to indicate if you have ever experienced the following;
Anxiety yes/no past/present/ both
Depression yes/no past/present/ both
Suicide Attempt yes/ no past/present/ both
Thoughts of Suicide yes/ no past/present/ both
Hallucinations yes/ no past/present/ both
Gambling Problems yes/no past/ present/ both
Excessive Use of Facebook yes/no past/present/ both
Excessive Gaming, or Internet Use yes/ no past/present/ both
Sexual/Pornography addiction past/present/ both
Sexual Abuse/Exploitation yes/no past/present/ both
Physical Abuse yes/ no past/present/ both
Significant losses yes/ no past/present/ both
Repeated risky behaviors yes/ no past/present/both
Work or school problems yes/ no past/present/ both
Emotional abuse by others yes/ no past/present/ both
Obsessive/Compulsive Behaviors yes/no past/present/ both
Issues of Sexual Identity yes/no past/ present/ both
Career Crisis yes/no past/ present/ both
Legal Troubles yes/no past/ present/ both
- Excessive use is defined as that which gets in the way of relationships, self-care, work, etc.
- Place a circle around the word that describes your situation: married divorced never married co-habitating
Are you currently in a romantic relationship? □ No □ Yes
If yes, for how long? ______
On a scale of 1-10, how would you rate your satisfaction in this relationship? ______
What significant life changes or stressful events have you experienced recently?
______
Who do you trust to be supportive of you?______
FAMILY MENTAL HEALTH HISTORY:
Who lives in your home?
Name Relationship Age
______
______
______
Are there any pets living with you? If yes, Please provide names and species:
______
Who raised you?______Are you adopted?______
______
Names and ages of any siblings:
In the section below identify if there is a family history of any of the following. If yes,
please indicate the family member’s relationship to you in the space provided (father,
grandmother, uncle, etc.).
Please Circle List Family Member
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
Criminal Behavior yes/no
Chronic Health Problems yes/no
Sexual Abuse/Exploitation yes/no
Physical Abuse yes/no
Domestic Violence yes/no
ADDITIONAL INFORMATION:
Are you currently employed? □ No □ Yes
If yes, how long have you worked at your current job?______What do you
do?______Do you have regular hours?______
Do you work night shifts?______
Have you been in the Military?______Were you deployed?______
Are you in a College or Training Program?______Is so, where?______
What are you studying?______
Do you enjoy your work/school? Is there anything stressful about your current work/school?
______
Do you consider yourself to be spiritual or religious? □ No □ Yes
If yes, describe your faith or belief:
______
What do you consider to be some of your strengths?
______
______
What do you consider to be some of your weakness?
______
______
What concerns do you have about seeing a Therapist?
What questions, if any, do you have about therapy itself?
What would you like to accomplish out of your time in therapy?
______
______
Comments you would like to include;