Client Intake Form

INTAKE FORM


Please complete this secure form prior to our first appointment. The questions are designed to help me begin to understand you so that our time together can be as productive as possible. Please try to answer all the questions to the best of your ability. During our first in-person appointment, I will inquire further into certain areas as needed. Please feel free to add any additional information you think is important for me to know. Finally, please let me know if you have any questions or concerns about completing this form. Thank you.

 

Demographic Information

Name:
Street Address:
City:
Zip Code:
Primary Contact #
Alternate Contact #
Okay to leave a voicemail message?
Yes
No
Email Address:
SSN:
Age: 
DOB: 
Race/Ethnicity: 
Occupation: 
Employer: 

 

Emergency Contact

Name: 
Relationship: 
Telephone (Day): 
Telephone (Evening): 
Street Address:
City:
Zip Code:

 

Mental Health History

1. Referred by:
 Medical Provider: 
 Website at (www.drerinjoyce.com)
 Psychology Today website
 Friend/Family: 
 Other: 

2. Briefly, what brings you in to therapy now? 

3. When did your problem(s) first start? Within the last:
 30 days
 6-12 months
 2 years
 During adolescence
 During childhood

4. What areas of your life have been affected because of this problem?

5. Have you previously received any type of mental health services either for this problem(s) or others?
Yes
No

6. If yes to q. 5, please check all that apply:
 Psychotherapy
 Psychiatric Medication
 Outpatient Hospitalization or Day Treatment Program
 Inpatient hospitalization

a) Please briefly explain the reason for receiving the above previous mental health treatment.

7. Are you currently experiencing overwhelming sadness, grief or depression?
Yes
No

a) If yes, for approximately how long?  

b) If yes, have you felt so badly that you’ve had thoughts of not wanting to be here anymore or of killing yourself?
Yes
No

8. Do you have a history of suicidal thoughts or any suicide attempts?
Yes
No

If yes, please explain.

9. Do you have a history of engaging in any self-harm behaviors, e.g., cutting?
Yes
No

If yes, please explain.

10. Are you currently experiencing anxiety, panic attacks or any phobias?
Yes
No

If yes, please explain.

11. Have you experienced any abuse or traumatic events at any point in your life?
Yes
No

If yes, please describe briefly if you feel comfortable doing so.

12. Have you experienced any significant losses at any point in your life?
Yes
No

If yes, please explain briefly.

13. Please describe current use of alcohol, tobacco and/or recreational drugs:

14. Please describe any past use of alcohol, tobacco and/or recreational drugs:

15. Do you have a history of any physical violence or assault towards others?
Yes
No

16. Do you have a history of any significant legal problems, e.g., court-mandated therapy or mental health treatment, arrests, lawsuits (either as plaintiff or defendant)?
Yes
No

17. Have you experienced any significant life changes or stressful events recently?

18. What are the main ways you cope with stress?

 

Family & Relationship History

19. Briefly describe your upbringing (parents/caregivers, siblings, home environment, school performance, any abuse, other significant events).

20. Any family history of mental illness?
Yes
No

21. Any family history of suicide?
 No
No

22. Sexual Orientation:
Heterosexual
Gay/Lesbian
Bisexual
Other: 

23. Relationship Status:
 Single
 In A Relationship
 Married
 Domestic Partner
 Separated
 Divorced
 Widowed

24. If applicable, on a scale of 1-10 (best), how would you rate your relationship?

25. Do you have any children?
Yes
No

If yes, please list the gender and age of each.

26. What do you consider to be your closest relationships or primary source of social/emotional support?

 

Physical Health History

27. How would you rate your current physical health?
 Poor
 Unsatisfactory
 Satisfactory
 Good
 Very good

28. Please list any specific health problems you are currently experiencing:

29. Please list any medications, herbs or supplements you are currently taking, including any psychiatric medications.

30. How would you rate your current sleeping habits?
 Poor
 Unsatisfactory
 Satisfactory
 Good
 Very good
 Excellent

31. How would you rate your current eating habits?
 Poor
 Unsatisfactory
 Satisfactory
 Good
 Very good
 Excellent

32. Please briefly describe your diet and exercise habits, and how you view your weight and body image.

33. Are you currently experiencing any chronic pain?
Yes
No

If yes, please describe briefly, including how you are managing it.

 

Additional Information

34. Are you employed or in school?
Yes
No

If yes, briefly describe your experience, i.e., quality of your performance, what you like and dislike, etc.

35. What do you enjoy doing in your free time? What do you do to relax?

36. Do you consider yourself to be spiritual or religious?
Yes
No

If yes, please describe briefly:

37. What do you see as your greatest personal strengths and achievements?

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

39. If you were living your ideal life, what about your current life would be different?

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

 

Client Signature:
Date:

**All fields must be completed in order to successfully submit this form