Intake Form
All information given will be kept confidential.
Client Information
Name
First Name
Last Name
Address
Street
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Gender
Please Select
Male
Female
Age
Birth Date
-
Month
-
Day
Year
Date
How would you rate your physical and emotional well-being?
Not Functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not Functioning, 10 is No Problems
What is it that you would like / want for yourself from our work together? (If this is not clear we could explore this question inn our first meeting)
How well you sleep?
Very well
I wake up often
Short
Irregular
Females: Do you have any problems with your reproductive organs or menstrual cycle?
yes
no
Please indicate if there is a family history of any of the following conditions;
Rows
Yes
No
Indicate Family Member
Anxiety
Depression
Substance Abuse / Alcohol
Arrested
Obesity
Schizophrenia
Suicide Attempt
Domestic Violence
How would you rate your family relationship?
Not functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not functioning, 10 is No Problems
History
Have you previously received any type of therapy?
Yes
No
Are you currently on psychiatric medication?
Yes
No
Please list psychiatric medicines that you took or are taking currently;
General Health Information
How would you rate your physical health condition?
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
How often do you exercise?
None
1
2
3
4
5
6
7
8
9
Very Often
10
1 is None, 10 is Very Often
How would you describe your general appetite?
Very Poor
1
2
3
4
5
6
7
8
9
Very Hungry
10
1 is Very Poor, 10 is Very Hungry
How would you describe your energy level throughout the day?
Very Relaxed
1
2
3
4
5
6
7
8
9
Very Stressed
10
1 is Very Relaxed, 10 is Very Stressed
Please answer all of the statements below that describe your emotional states
Rows
Never
Sometimes
Very often
Fear of many things
Guilt
Joy
Friendliness
Avoiding people
Sadness
Sexual issues
Depression
Stability
Hope
Having nightmares
Anxiety
Connection
Discomfort in social situations
Submit
Should be Empty: