Client Intake Form

1377 Tamarack Ave Boulder C0 80304

(303) 859-7410

Please fill in the information below and submit
Please note: information provided on this form is protected as confidential information.

Personal Information

Name

Date

Parent/Legal Guardian (if under 18)

Address

Home Phone

Cell/Work/Other Phone

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Date of Birth

Age

Gender

Referred By (if any):

History

If yes, Previous therapist/practitioner

If yes, please list:

If yes, please list and provide dates.

General and Mental Health Information

Please list any specific health problems you are currently experiencing.

Please list any specific sleep problems you are currently experiencing.

3. How many times per week do you generally exercise?

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

If yes, please describe

If yes, please describe.

If yes, for how long?

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

Family Mental Health 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 in the space provided (e.g. father, grandmother, uncle, etc.)

List Family Member

Additional Information

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

If yes, describe your faith.

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

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

Short text field

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