New Patient Intake Questionnaire -

Patient Details

First Name

Last Name

Date of Birth

Personal Information (Optional - please only complete these questions if you feel comfortable doing so)

Gender Identity (if different)

Identified Pronouns

Sexual Orientation

Race/Ethnic Identity

Religion (if applicable)

Family Information (please list all other members living in the same household with the patient)

No other household members

Add Family Member

Providers

No providers to list

Add Provider

Previous Services

Were you referred to our practice?

Yes No

Who referred you?

Have you sought counseling in the past?

Yes No

If yes, please explain:

Medications

The patient is not currently taking any medications

Medication List Attached

Attach Copy of Medication List Please click here to upload a copy of the patient's medication list

Add file

Please upload a file

Add Medication

Medical History

Patient has no current medical conditions

Please list any current medical conditions

Patient has no previous medical conditions

Please list any previous medical conditions

Have you had any previous surgeries?

Yes No

If yes, please explain

Educational/Employment Information

Not presently employed

Current Occupation

Job Title

Highest Educational Level Achieved

Other Information

Do you have any current or previous legal issues?

Yes No

If so, please describe

Do you experience any issues with appetite or sleep?

Yes No

If so, please describe

Please list one personal strength

Please list one personal weakness

What do you like to do to relax?

Reason for Consultation

Please describe the problem(s)/concern(s) that brought you here:

What do you hope to achieve in therapy?

Is there any other information you would like us to have that isn't listed anywhere else?

Thanks for trusting us to help you! If at any point you have any questions or concerns about the treatment you receive, please let your therapist know.

Your information will be encrypted.

New Patient Intake Questionnaire

Patient Details

Personal Information (Optional - please only complete these questions if you feel comfortable doing so)

Family Information (please list all other members living in the same household with the patient)

Providers

Previous Services

Medications

Medical History

Educational/Employment Information

Other Information

Reason for Consultation

Psychological Services of Central Illinois, P.C.