Client Intake Questionnaire

For life-threatening emergencies, please call 911 or go to the nearest emergency room

Personal Information

First Name (legal)

Last Name

Nick Name

Occupation

Short description

Home address

City

State

Zip Code

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Mobile Phone

Please enter in this format: xxx-xxx-xxxx

Other Phone

Emergency Contact Name

ER Contact Phone

DOB

Age

Gender

Ethnicity

Sexual Orientation

Marital Status Chose best option

Never Married Domestic Partnership Married Separated Divorced 2nd+ Marriage Widowed

Children (type NA if none)

Include first names, ages

Siblings

Include first names, ages

Referred By (if any)

Highest education level

Current living situation

e.g. who lives with you, what type of housing

History

If yes to either question above, explain below

Presenting issue

Describe what brings you to therapy, brief symptoms, length of time you've experienced this

Previous behavioral/mental health services received

Brief description of treatment focus or NA if none

Previous therapist/practitioner

Name and phone number if you give permission for a consult

List of current psychiatric medicine

Name, dose, approx. start date, condition, prescribing doctor, or NA

General Health Information

Current non-psychiatric medications

Name, dosage, approx start date, condition it's treating or NA if none

How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific physical health problems you are currently experiencing:

How would you rate your current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise do you participate in?

Please list any difficulties you experience with your appetite or eating problems:

Enter NA or None if this doesn't apply

If yes, for approximately how long?

Include approximate age of onset and factors affecting you

If yes, when did you begin experiencing this?

Be specific

If yes, please describe:

Frequency of Cannabis use

Enter None if this doesn't apply

How often do you engage in recreation drug use?

Daily Weekly Monthly Infrequently Never

If yes, for how long?

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

Include dates or time frame or enter none if this doesn't apply

History of trauma/abuse

Enter none or NA if this doesn't apply

Family Mental Health/Behavioral History

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 (e.g. father, grandmother, uncle, etc.)

Family Member

Describe family life growing up

Include socio-cultural environment, family rules, discipline methods, etc.

Relationship with mother/mother figure growing up

Non-existent/absent Poor Fair Complicated Good Very satisfying

Relationship with father/father figure growing up

Non-existent/absent Poor Fair Complicated Good Very satisfying

Describe relationship with parental figures currently

Check all that apply

Father/father figure is deceased

Father/father figure is still alive

Mother/mother figure is deceased

Mother/mother figure is still alive

I have step family

I was adopted

I am estranged from family

Additional Information

Check all that apply

Employed full time

Employed part time

Self employed

Unemployed

Full time student

Part time student

Describe your current work / school satisfaction

Include any concerns/issues that might be focus of therapy

List your current work / school schedule during the week

Spiritual/Religious orientation

Enter none if not applicable

Rate importance of spiritual beliefs in daily life

None/not practicing Somewhat important Very important

Legal issues/concerns

Check if you've served time in prison and/or have current/pending legal proceedings that may affect therapy

Current legal issues

Military service

Include branch, dates, and combat experience

Describe your personality including strengths/weaknesses

Give a brief description including if you see yourself as outgoing or reserved

Social supports and other interests

List those who offer moral support and/or any hobbies or leisure activities you enjoy

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

Check the following boxes to indicate you have read, understand and agree to the terms outlined in the following forms. These forms may be downloaded from ListerCounseling.com under the Helpful Forms tab.

Telehealth Disclosure

Informed Consent

HIPAA

Your information will be encrypted.

CHRISTINE LISTER LMFT#50744

Providing individual and family counseling to improve relationships. I especially focus on issues related to anxiety, grief (including loss of spouse), anger management, and depression. When applicable, I use faith-based approaches.

cell: 714-906-1689, fax: 714-551-6833
ListerCounseling.com
26359 Jefferson Ave, Murrieta, CA, 92562, United States