Therapy Intake Form (Adult)

Emergency Assistance

If this is an emergency, call:

Crisis Line: (256) 716-1000
911

Client Information

First name

Middle Initial

Last name

Date of birth

Gender

Contact Information

Phone number

Email address

Address

Please upload an image of your Photo ID (eg: Driver's License - or if adolescent any snapshot):

PHOTO ID:

Add file

Please upload a file

Can we contact you by phone, email, and voicemail?

Yes No

If no, what is your preferred method of communication?

Emergency Contact

Add another emergency contact

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

Yes No

Current / Prior Treatment

Have you previously received therapy?

Yes No

If yes, where did you receive care and for how long?

Have you ever been prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

Medical History

How is your physical health at present?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any persistent physical symptoms or health concerns (eg: chronic pain, headaches, hypertension, diabetes, etc.):

Are you pregnant?

Yes No Not sure

If yes, how far along?

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

Family History

Are you currently in a romantic relationship?

Yes No

If yes, how long have you been in this relationship?

On a scale of 1-10 how would you rate the quality of your current relationship?

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

Do you have any children?

Yes No

If yes, briefly describe your relationship with your children.

Briefly describe your relationships with your parents.

Do you have any siblings?

Yes No

Briefly describe your relationship with your siblings.

Family Mental Health History:

Has anyone in your family (either immediate family members or relatives) experienced difficulties with any of the following? (check any that apply and list family member: eg: sibling, parent, uncle, etc)

Depression

Yes No

Family Member

Bipolar Disorder

Yes No

Family Member

Anxiety Disorder

Yes No

Family Member

Panic Attacks

Yes No

Family Member

Schizophrenia

Yes No

Family Member

Alcohol/Substance Abuse

Yes No

Family Member

Eating Disorders

Yes No

Family Member

Learning Disabilities

Yes No

Family Member

Trauma History

Yes No

Family Member

Suicide Attempts

Yes No

Family Member

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

Personal History

What is your highest level of education?

Are you currently employed?

Yes No

If yes, what is your current occupation?

Do you use drugs?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you drink caffeine?

Regularly Occasionally No

Do you gamble?

Regularly Occasionally No

Do you exercise?

Regularly Occasionally No

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

Do you have any problems with your sleep habits?

Yes No

If yes, check where applicable:

Sleeping too little

Sleeping too much

Poor quality sleep

Disturbing dreams

Do you have any difficulty with your appetite or eating habits?

Yes No

If yes, check where applicable:

Eating less

Eating more

Bingeing

Restricting

Have you experienced significant weight change in the last 2 months?

Yes No

Have you had suicidal thoughts recently?

Frequently

Sometimes

Rarely

Never

Have you had them in the past?

Frequently

Sometimes

Rarely

Never

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

What do you consider to be your strengths?

What do you like most about yourself?

What are effective coping strategies that you've learned?

Reasons for Visit

Describe the reasons you are seeking therapy.

Describe any goals or outcomes you hope to achieve from therapy.

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

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

Your information will be encrypted.

Therapy Intake Form (Adult)

Emergency Assistance

Client Information

Contact Information

Emergency Contact

Current / Prior Treatment

Medical History

Family History

Family Mental Health History:

Personal History

Reasons for Visit

Emergency Assistance

N. Gail Seemann, LPC

Licensed Professional Counselor, Lifestream Family Counseling