Adult and Couples Intake Form

This form typically takes between 5 and 15 minutes to complete. It cannot be saved to complete later. If you are coming as a couple, you must each fill out your own copies.

This is a confidential and HIPAA compliant encrypted form. The information here will be given to your therapist and uploaded to your personal electronic health record, visible only to your therapist and if applicable, their supervisor. If you have questions about how this information will be used, please call your therapist. If you're using insurance, your insurance company may request your file to determine medical necessity, including this information.

Based on this information your therapist may have additional assessments to complete in person.

**If there is any information you don't want discussed in front of your partner in the intake, please make a note of that.**

Therapist Name

Patient Name

Patient Date of Birth

DSM-5 Self rated Level 1 Cross Cutting Symptom Measure Adults

The questions below ask about things that might have bothered you. For each question, mark the number that best describes how much (or how often) you have been bothered by each problem in the PAST TWO WEEKS.

0 - None, not at all
1 - Slight, rare less than a day or two
2 - Mild, several days
3 - Moderate, more than half of days
4 - Severe, nearly every day

1) Little interest or pleasure in doing things

0 1 2 3 4

2) Feeling down, depressed, or hopeless?

0 1 2 3 4

3) Feeling more irritated, grouchy, or angry than usual

0 1 2 3 4

4) Sleeping less than usual, but still have a lot of energy?

0 1 2 3 4

5) Starting lots more projects than usual or doing more risky things than usual?

0 1 2 3 4

6) Feeling nervous, anxious frightened, worried or on edge?

0 1 2 3 4

7) Feeling panic or being frightened?

0 1 2 3 4

8) Avoiding situations that make you nervous?

0 1 2 3 4

9) Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?

0 1 2 3 4

10) Feeling that your illnesses are not being taken seriously enough?

0 1 2 3 4

11) Thoughts of actually hurting yourself?

0 1 2 3 4

12) Hearing things other people couldn't hear, such as voices even when no one was around?

0 1 2 3 4

13) Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?

0 1 2 3 4

14) Problems with sleep that affect your sleep quality overall?

0 1 2 3 4

15) Problems with memory (e.g., learning new information) or with location (e.g., finding your way home?

0 1 2 3 4

16) Unpleasant thoughts, urges or images that repeatedly enter your mind?

0 1 2 3 4

17) Feeling driven to perform certain behaviors or mental acts over and over again?

0 1 2 3 4

18) Feeling detached or distant from yourself, your body, your physical surroundings or your memories?

0 1 2 3 4

19) Not knowing who you really are or what you want out of life?

0 1 2 3 4

20) Not feeling close other people or enjoying your relationships with them?

0 1 2 3 4

Are you concerned for your safety or the safety of those around you because of any of the following:

Suicidal

Assaulting others or being violent

Relapse or drug use

Sexual behavior that is risky to your health or illegal

NONE OF THE ABOVE

Chief complaint or presenting problem

Description of Present Problem

What made it important to seek help with this problem right now?

What have you already tried to take care of this problem?

When did you first start to struggle with this problem?

If this problem were to go away - or it were to be totally resolved, what would you be doing differently or how would you know it had been resolved?

Psychiatric History

Previous Counseling

Please list past counseling experience including counselor name, dates seeing them, issues that were being addressed, what was the MOST helpful things from that counselor and if you'd like to me contact them. If none - type NONE.

Past psychiatric hospitalizations

Please list locations, dates, and reason for admittance. If none - type NONE.

Past Substance Use Treatment

Please list providers, dates and substance use addressed. If none, type NONE

Trauma History

Please describe any trauma history, related or unrelated. This may include history of bullying, physical assaults, combat, discrimination, natural disaster, sexual assaults, sexual molestations, life threatening accidents, childhood verbal / emotional / physical abuse, childhood emotional or physical neglect, intimate partner violence.

Are any of your trauma experiences related to the issue that brought you to counseling this time?

Family Psychiatric History

Is there a family history of depression, anxiety, bipolar, OCD, schizophrenia or substance use on either your mother or father's side of the family?

Medical Issues

Primary Care Physician and date of last physical

Current physical or mental health conditions

Please list the condition, and treatment provider giving support.

Describe your exercise habits

What kind, how often, how intense

Sleep issues

How much sleep do you usually get and is it restful? Describe any sleep disturbance issues such as sleep apnea, sleep walking, restless leg or disruption from family sleeping situations.

History of head trauma

Any situations where you hit your head and lost consciousness or diagnosed head / brain trauma.

Please list ALL your current medications, not just those for mental health.

Medication name, milligrams, number of pills, how many times a day and prescriber.

21) Drinking at least 4 drinks of any kind of alcohol in a single day?

0 1 2 3 4

22) Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?

0 1 2 3 4

Would you like help quitting tobacco products?

23) Using any of the following medicines ON YOUR OWN, that is without a doctor's prescription, in greater amounts or longer than prescribed (e.g., painkillers (like Vicodan), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or valium), or drugs like marijuana, cocaine, or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?

0 1 2 3 4

Which medicines or drugs are you referencing in number 23 (if any)?

Family History

Tell us about your parents

Biological parents, adoptive parents, culture/ethnicity, etc. Are they still married or at what age (yours) did they divorce? Other people important in your upbringing (e.g., step parents, grandparents, etc.)

Describe your relationship with your parents.

How was it growing up, did it improve in adulthood.

Siblings

Please list your siblings from oldest to youngest (include yourself) and how many years older or younger they are. Please note any IMPORTANT step sibling relationships.

Faith preferences

Do you have a spiritual / religious community or faith that you want your clinician to consider when working on treatment planning. Do you identify as agnostic or atheist and prefer not have this discussed?

Social History

Previous relationships / marriages

Please list SIGNIFICANT previous marriage/partner(s), years together and any children

Current Relationship

Who is your current partner? Please describe the relationship (married, dating, living together, open, etc). When did you meet? Move in together? Get married?

Children

Please list children and their ages

Current Life Stressors

What, if any current life stressors (e.g., work, unemployment, health issues, parenting, caring for elder parents, etc.) are causing stress in your relationship?

If you are coming for Marriage / Couples Counseling, which of the following area(s), if addressed, would most improve your marital satisfaction.

Communication

we argue or bicker a lot and can’t seem to let it go.

Intimacy

we work well as a team, but we don’t feel connected anymore

Passion

feeling passionate, desirous and sexually attractive is missing.

Problem solving

issues like chores, parenting and financial problems

Affair Recovery

need help rebuilding trust & connection following an affair.

Sexual issues

libido, erectile dysfunction, premature/delayed orgasm, etc

Compulsive/addictive behavior

drug /alcohol, gambling, pornography

Unsure about relationship

trying to decide whether or not to divorce

Education and Occupational History

Please list diploma’s, certifications and degrees earned starting with high school.

Degree/major, school/university, date graduated.

Any educational accommodations in high school or college?

Formal IEP accommodations or 504 plan.

Employment History

Please list last 5 years of jobs, dates and reason for leaving.

Describe any military experience

Legal History

Please list any past charges, convictions (if any) and sentences.

Describe any Legal issues that you currently have a lawyer representing you for.

Divorce, child custody, criminal or drug court, etc. Do any of these issues relate to why you or your partner is in counseling now? Did your lawyer ask you to get counseling? Do you expect that you'll be asking your therapist to have input on these cases?

Your information will be encrypted.