Client Intake Questionnaire

Please correct the errors described below.

Personal Information

Short description
I use encrypted email that requires you to create a secure pass phrase
Include first names, ages
e.g. who lives with you, what type of housing

History

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
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

Enter none if not applicable
Include branch, dates, and combat experience
List those who offer moral support and 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 ListerCounseling.com under the Helpful Forms tab.

Your information will be encrypted.

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