Client Intake Questionnaire

Please correct the errors described below.

Personal Information

Short description
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Please enter in this format: xxx-xxx-xxxx
Include first names, ages
Include first names, ages
e.g. who lives with you, what type of housing


Describe what brings you to therapy, brief symptoms, length of time you've experienced this
Brief description of treatment focus or NA if none
Name and phone number if you give permission for a consult
Name, dose, approx. start date, condition, prescribing doctor, or NA

General Health Information

Name, dosage, approx start date, condition it's treating or NA if none
Enter NA or None if this doesn't apply
Include approximate age of onset and factors affecting you
Be specific
If you do not drink alcohol, select None
Enter None if this doesn't apply
Include dates or time frame or enter none if this doesn't apply
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.)

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

Additional Information

Include any concerns/issues that might be focus of therapy
Enter none if not applicable
Include branch, dates, and combat experience
Give a brief description including if you see yourself as outgoing or reserved
List those who offer moral support and/or any hobbies or leisure activities you enjoy

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 under the Helpful Forms tab.

Your information will be encrypted.