Client Intake Form

Emergency Assistance

If this is an emergency, call:

Crisis Line: (888) 724-7240
911

First name

Last name

Contact Information

Phone number

Email address

Address

Can we contact you by phone, email? * Email is not considered to be a confidential medium of communication.

Yes No

If no, what is your preferred method of communication?

Reasons for Visit

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

Anything else that you would like me to know?

Describe any significant life changes or stressful events that you have recently experienced.

Is there anything else you'd like to tell us about?

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Medical History

Have you previously received therapy?

Yes No

If you have received therapy previously, for any specific issues?

Have you previously been prescribed psychiatric medication?

Yes No

What psychiatric medications are you currently taking?

What medications are you currently taking for medical conditions?

Is there anything regarding your medical history that we should be aware of?

Family History

Is there anything regarding your relationship/relationships you would like us to be aware of?

Do you have any children?

Yes No

If yes, briefly describe your children's ages, your relationship with your children.

Describe your relationships with your parents.

Do you have any siblings?

Yes No

Describe your relationship with your siblings.

Is there anything else regarding your family history that we should be aware of?

Ex: alcohol/substance abuse, sexual abuse, anxiety, depression, domestic violence, eating disorders, obesity, obsessive/compulsive behavior, schizophrenia, suicide attempts

Personal History

Are you currently employed?

Yes No

If yes, what is your current occupation?

How often do you engage in recreational drug use?

Daily Weekly Monthly Does not apply

Do you drink alcohol?

Regularly Occasionally No

How often do you get a full night of sleep?

Regularly Occasionally Never

Do you exercise?

Regularly Occasionally No

Do you have a healthy and balanced diet?

Regularly Occasionally No

How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very Good

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

Yes No

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

Yes No

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

Yes No

Is there anything else regarding your personal history that we should be aware of?

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