Confidential Intake Form

THANK YOU for your time and effort to fill out this important information.

Please complete this form prior to your first full session with me. This information is encrypted and completely confidential.

PERSONAL INFORMATION

First Name

Last Name

Mailing Address

City

State

Zip Code

Age

Date of Birth

Best Phone Number

Email address:

Please list any children and their ages:

Name of Parent or Guardian (if under 18):

Emergency Contact Name

Phone Number

How did you hear about me? Referred by (if any)

HEALTH HISTORY

Name of Physician (or Clinic)

Phone Number

Please briefly elaborate here if Unsatisfactory or Poor:

Please list any currently prescribed medications or supplements, for general or mental health:

Please list any previously prescribed mental health medications:

Have you previously been under the care of a psychiatrist, psychologist, or therapist?

Have you been hospitalized or gone to the emergency room for a mental health condition?

Do you or have you ever practiced any form of self-harm, such as cutting or self-mutilation?

Have you ever attempted or considered suicide, wished you were dead, or wanted to go to sleep and not wake up?

Have you ever been in a drug, alcohol, or addiction treatment program?

Do you currently drink alcohol?

Do you currently use recreational drugs?

Do you feel you have a problem with either alcohol or drugs?

Do you feel you have a problem with any other type of addiction?

Do you have any difficulties with your appetite or eating patterns? Or any recent weight gain or loss?

If you have issues with sleeping, please briefly explain:

Do you exercise regularly?

Are you currently experiencing overwhelming sadness, grief, or depression?

Are you currently experiencing anxiety, phobias, or having panic attacks?

Are you experiencing any chronic pain?

Are you currently in a romantic relationship?

Please rate on a scale from 1-10.

FAMILY MENTAL HEALTH HISTORY

ADDITIONAL RELEVANT INFORMATION

Are you currently employed?

Do you mostly enjoy your work and your life? Is there anything stressful I should know about?

Do you consider yourself to be spiritual or religious?

What would a friend or family member consider to be some of your strengths or best qualities?

What would a friend or family member consider to be some of your weaknesses or rough edges?

STATEMENT OF NEED

Please provide a brief description of your reasons for seeking counseling at this time.

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

What are your goals for our work together?

Is there anything else you think I should know?

Thank you for your time and effort to complete this form as thoroughly as possible. I look forward to working with you and learning more about you, your life, and your goals.

Your information will be encrypted.

Confidential Intake Form

THANK YOU for your time and effort to fill out this important information.

PERSONAL INFORMATION

HEALTH HISTORY

FAMILY MENTAL HEALTH HISTORY

ADDITIONAL RELEVANT INFORMATION

STATEMENT OF NEED

THANK YOU for your time and effort to fill out this important information.

Emily Sinclair, MA, LMHC