Date
MM
DD
YYYY
Name
First Name
Last Name
Age
Date of Birth
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone Number
(###)
###
####
Mobile Phone Number
(###)
###
####
Email
Marital Status? (Select all that apply)
If you answered married, separated, or divorced, for how long?
Ethnicity
Where did you grow up?
Did you meet all developmental milestones as a child?
If no, please explain.
Education Level?
Special Education Services?
If yes, please name services received.
Occupation
Emergency Contact (Name, Relationship, Phone, Address)
Please describe your current living arrangement (Do you live alone? With others?)
Have you participated in counseling before?
If yes, please explain when and what brought you to counseling at that time.
Are you currently seeing a psychiatrist, therapist, other?
Have you or another family member ever been hospitalized for issues related to mental health?
If yes, please provide dates and circumstances that led to hospitalization.
Substance Abuse/Addiction History?
If yes, please explain.
Family Substance/Addiction History?
If yes, please explain.
Legal History?
If yes, please explain: DWI, arrests, prison, etc.
Medical Information/Medication History
Please rate how strongly these problems or symptoms apply to you.
Marriage
Being Single
Sexual Issues
Family
Divorce/Separation
Child Custody
Disability
Work/Career
School/Learning
Money/Budgeting
Aging/Dependency
Weight Control
Alcohol/Drugs
Other Addictions
Grief/Loss
Depression
Fear/Anxiety
Anger Management
Loneliness
Mood Swings
Religion/Spirituality
Codependency
Communication
Self-Esteem
Stress Control
Spouse's Name (if applicable)
First Name
Last Name
Spouse's Age (if applicable)
Spouse's Occupation (if applicable)
I would describe my relationship with my spouse as:
Close
Somewhat Close
Distant
Conflicted
Other
Not applicable
If other, please explain.
I would describe my friendships as:
Close
Somewhat Close
Distant
Conflicted
Other
Not applicable
I would describe my relationship with my mother as:
Close
Somewhat Close
Distant
Conflicted
Other
Not applicable
I would describe my relationship with my father as:
Close
Somewhat Close
Distant
Conflicted
Other
Not applicable
How many siblings do you have?
I would describe my relationship with my siblings as:
Close
Somewhat Close
Distant
Conflicted
Other
Not applicable
If you answered other to any of the above, please explain.
Are you having any current suicidal feelings, thoughts, or actions?
If yes, please explain.
Any current homocidal or violent thoughts or feelings, or anger-control problems?
If yes, please explain.
Any issues, hospitalizations, or imprisonments for suicidal or assault behavior?
If yes, please explain.
Any current significant loss or harm (illness, divorce, custody, job loss, etc.)?
If yes, please explain.
Do you have a social support system? And if so, please list members.
How can we help? (Tell us in your own words what brings you here today)
What are two of your most important goals for therapy?
Who referred you to us?
We would be interested in your feedback regarding this intake form. If you have any feedback, please put your comments below!
