Client Intake Form 22

CLIENT INTAKE FORM
Date of first appointment:
Please take your time in providing the following information. The questions are designed to help me begin to
understand you so that our time together can be as productive as possible. All information provided is confidential.
Referred by:
Medical Provider:
Insurance Provider:
My Website: www.stokescounseling.com
PsychologyToday
Friend/Family:
Other:
Have you previously received any type of mental health services?

Yes
No
If yes, which of the following:
Psychotherapy
Medication
Outpatient Hospitalizations
Inpatient Hospitalization
If yes, please provide:

Name of provider or facility:
Location:
Dates of treatment:
Reason for treatment:
Briefly, what brings you in today
When did your problem first start? Within the last:

30 days
6--12 months
2 years
During adolescence
During childhood
What areas of your life have been affected because of this problem?
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?
Please describe any major losses or traumas you have experienced:
What significant life changes or stressful events have you experienced recently?
What would you like to accomplish out of your time in therapy
Family History
Where were you born?
Where did you grow up?
City
Suburbs
Country
Please list your parents and siblings. Please use additional space on the back if needed
Name Age Relationship Where do they live now? If deceased, age and cause of death
Who did you live with while growing up?
Mother's occupation:
Father's occupation?
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 (father, grandmother, uncle, etc.).
Condition Please circle List Family Member
Alcohol/Substance Abuse yes/no
Anxiety yes/no
Depression yes/no
Domestic Violence yes/no
Sexual Abuse yes/no
Eating Disorders yes/no
Obesity yes/no
Obsessive Compulsive Disorder yes/no
Schizophrenia yes/no
Suicide Attempts yes/no
yes/no : which was---
Other diagnosed mental health condition?
Marital Status:
Never Married
Domestic Partner
Married
Separated
Divorced -- For how long?
Widowed: Please provide your partners name and year deceased:
If married, how long have you been married for and what is your partners name:
On a scale of 1-10 (best), how would you rate your relationship?
Are you currently in a romantic relationship?

Yes -- How long?
No
On a scale of 1-10 (best), how would you rate your relationship?
Please list any children, their names, and ages:
Name Age Relationship Name of other parent If deceased, age and cause of death
Physical Health
Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are
prescribed for off-label use. Continue on the back if needed, or provide a separate list. If you have a complicated
medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of
your health.
Medication/Supplement Dosage Condition NameBegan/Stopped
Prescribing provider and contact information:
Name:
Specialty:
Facility:
Phone, email, or Fax:
How would you rate your current physical health?

Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any specific health problems you are currently experiencing:
How would you rate your current sleeping habits?

Poor
Unsatisfactory
Satisfactory
Good
Very Good
If you are having problems, in which phase of sleep are you experiencing issues?
Falling asleep
Staying asleep
Awakening early
Sleep apnea
Please list any other specific sleep problems you are currently experiencing:
How many times per week do you generally exercise? What types of exercise do you participate in:
Are you currently experiencing any chronic pain?

No
Yes
If yes, please describe:
Please describe current use of alcohol, cigarettes, and/or recreational drugs:
Please describe previous use of alcohol, cigarettes, and/or recreational drugs:
Additional Information
What do you enjoy about your work (full-time homemaker included)? If retired, what did you enjoy about your work?
What do you find particularly stressful about your current or previous work?
What do you enjoy doing in your free time? What do you do to relax?
Do you consider yourself to be spiritual or religious? If yes, please describe your faith or belief:
What do you consider to be some of your strengths?
What do you consider to be some of your weakness?

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CLIENT INTAKE FORM

Date of ﬁrst appointment:

Have you previously received any type of mental health services?

If yes, please provide:

Brieﬂy, what brings you in today

When did your problem ﬁrst start? Within the last:

Are you currently experiencing overwhelming sadness, grief or depression?

If yes, for approximately how long?

Please describe any major losses or traumas you have experienced:

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

Where were you born?

Where did you grow up?

Who did you live with while growing up?

On a scale of 1-10 (best), how would you rate your relationship?

Are you currently in a romantic relationship?

On a scale of 1-10 (best), how would you rate your relationship?

Please list any children, their names, and ages:

Medication/Supplement Dosage Condition NameBegan/Stopped

Prescribing provider and contact information:

Phone, email, or Fax:

How would you rate your current physical health?

How would you rate your current sleeping habits?

Are you currently experiencing any chronic pain?

Please describe current use of alcohol, cigarettes, and/or recreational drugs:

Please describe previous use of alcohol, cigarettes, and/or recreational drugs:

What do you consider to be some of your strengths?

What do you consider to be some of your weakness?

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