Client Intake Questionnaire

History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

Yes No

Previous therapist/practitioner

Are you currently taking any prescription medication?

Yes No

If yes, please list

Have you ever been prescribed psychiatric medication?

Yes No

If yes, please list and provide dates

General and Mental Health Information

How would you rate your current physical health?

Please list any specific health problems you are currently experiencing

How would you rate your current sleeping habits?

Please list any specific sleep problems you are currently experiencing

How many times per week do you generally exercise?What types of exercise do you participate in?

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

Are you currently experiencing overwhelming sadness, grief or depression?

Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks or have any phobias?

Yes No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Yes No

If yes, please describe

Do you drink alcohol more than once a week?

Yes No

How often do you engage in recreational drug use?

Are you currently in a romantic relationship?

Yes No

If yes, for how long? On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship? What significant life changes or stressful events have you experienced recently?

Family Mental Health History

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.)

Work, Faith and Goals

Are you currently employed?

Yes No

If yes, what is your current employment situation? Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious?

Yes No

If yes, describe your faith or belief What do you consider to be some of your strengths? What do you consider to be some of your weaknesses? What would you like to accomplish out of your time in therapy?