Client Intake Form

Current Concerns

Briefly describe your primary concerns for seeking therapy.

When did these concerns begin?

What are your goals for therapy?

How intense is your emotional distress? (Mild) 1 2 3 4 5 6 7 8 9 10 (Severe)

Please describe.

Overall, how much do the problems affect your ability to perform at work or school, get along with others, and perform daily tasks such as chores? (Mildly disruptive) 1 2 3 4 5 (Incapacitating)

Please describe.

Have you experienced any major life changes or losses recently?

Yes No

If yes, please explain.

Mental Health History

Have you ever seen a therapist or counselor before?

Yes No

If yes, when and for what reason?

Have you ever been hospitalized for mental health concerns?

Yes No

If yes, please explain.

Have you ever engaged in self harm?

Yes No

If yes, when?

Have you ever experienced suicidal thoughts or urges to hurt yourself?

Yes No

If yes, when?

Have you ever attempted suicide?

Yes No

If yes, when?

Have you ever experienced homicidal thoughts or urges to hurt others?

Yes No

If yes, when?

Psychiatric and Medical History

Please list any psychiatric or mental problems you have been diagnosed with.

Please list any medical or physical problems that you have been diagnosed with.

Please list any medications you currently take, and what you take them for.

Strengths

Please list your top 3 coping skills.

Describe your social support system.