Client Intake

Name

Date

Address

Phone Number

Email address

Date of Birth

Age

Gender

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.) If yes, please list your previous therapist/practitioner

Have you ever been prescribed psychiatric medication? If yes, please list and provide dates:

Please list any specific health problems you have had:

Are you currently experiencing overwhelming sadness, grief or depression? If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks or have any phobias If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain? If yes, please describe

Are you currently in a romantic relationship? If yes, for how long?

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?

What significant life changes or stressful events have you experienced recently?

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.

Family Member

If yes, what is your current employment situation?

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 weaknesses?

What would you like to accomplish out of your time in therapy?

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