Ohio Psychotherapy and Consultation Services, LLC
Shawn D. King, Ph.D., LISW-SUPV
INTAKE HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential
and will become part of your medical record. (Double left click on all check boxes you want to check and type in rectangular boxes
to enter text)
Marital status:
Name
(First, M.I., Last):
Single
Date:
Partnered
Divorced
Gender Identity
Married
Separated
Widowed
Mobile Phone:
DOB:
Home Phone:
Referral Source:
Health Professional (who)?
Psychology Today
EAP Provider
Insurance Company Website
Other (please identify)
Work Phone:
Do you have a psychiatrist? If so please provide name:
Preferred Phone:
Other Phone:
Email Address:
Social Security number:
Are Appointment Email Reminders okay?
Address Line 1:
Yes
Address Line 2:
No
Are Phone Voice Mail messages okay on preferred phone?
City/State/Zip:
Yes
No
DEMOGRAPHIC INFORMATION
(1) Please provide your age, race/ethnicity, level of religiosity or spirituality, and marital or partner status.
(2) Do you have any current suicidal thoughts? Yes
Do you have a plan Yes
No
No
If so, do you have an intent to act Yes
? Are you having any homicidal thoughts? Yes
No
?
No
NOTE: If you are having any suicidal or homicidal thoughts outside this office go to the nearest emergency room and they will
evaluate you and give you needed help and support.
(3) Who is your emergency contact? Name, Address, Phone number(s) and relationship to you.
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Ohio Psychotherapy and Consultation Services, LLC
Shawn D. King, Ph.D., LISW-SUPV
(4) What brings you into Therapy?
(5) What are your current symptoms for what brings you to therapy? When did these symptoms start? What is the frequency? What
is the severity - Mild, Moderate, or Severe?
Symptom(s)
When Started
Frequency
Severity (mild, moderate, severe)
(6) Prior Treatment History
Prior Mental Health Treatment provider or
inpatient hospital or treatment center
Inpatient or
Outpatient
Date began
Date Ended
Diagnos(es)
(7) Is there any current or past Traumatic events in your life? What were the events? When did these events occur? Who were the
individuals involved?
(8) What is your family's history of mental health issues including drug and alcohol (name the individual(s) and their relationship to
you), and what was their diagnos(es) if any?
(9) What are your past and current medical conditions including treatments?
(10) Who is Your Primary Care Physician?
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Ohio Psychotherapy and Consultation Services, LLC
Shawn D. King, Ph.D., LISW-SUPV
(11) How do you Rate your health, (Very good, Good, Fair, or Poor)?
(12) How many regular size alcohol drinks (6 oz of alcohol or 12 oz beer) do you have in an average week?
Are you concerned about the amount you drink?
Yes
No
Have you considered stopping?
Yes
No
Have you ever experienced blackouts?
Yes
No
Are you prone to “binge” drinking?
Yes
No
Do you drive after drinking?
Yes
No
Do you currently use recreational or street drugs?
Yes
No
What type of drugs have you used?
(13) Please list all past and current medications for both physical and mental health including dosage, purpose, and the name of the
prescribing physician?
(14)Personal
Safety
Do you live alone?
Yes
No
Yes
No
Who do you live with? (name all and relationship to you):
Physical and/or mental abuse have also become major public health issues in this country. This
often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would
you like to discuss this issue with your provider?
(15) What is the quality of your relationship with your mother and father if still alive, siblings and how many siblings do you have?
What is the quality of your relationship with your spouse or partner? And, name any other significant family relationships important
in your life and the quality of those relationships.
(16) Who are your social supports? What is the nature and quality of those relationships?
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Ohio Psychotherapy and Consultation Services, LLC
Shawn D. King, Ph.D., LISW-SUPV
(17) MENTAL HEALTH
Is stress a major problem for you?
Yes
No
Do you feel depressed?
Yes
No
Do you panic when stressed?
Yes
No
Do you have problems with eating or your appetite?
Yes
No
Do you cry frequently?
Yes
No
Have you ever attempted suicide?
Yes
No
Have you ever seriously thought about hurting yourself?
Yes
No
Do you have trouble sleeping?
Yes
No
(18) Have you had any past or current developmental issues in school or occupation?
(19) What is your highest level of education and what is your current occupation?
(20) What are your past arrest if any? What is your past sentencing history? Any incarcerations? Do you have any DUI's? Do you
have an litigations? When did any of these occur? Are you currently in any custody situations? Are you currently on parole or
probation (if so which court and who is your parole or probation officer)?
(21) What are your personal strengths?
(22) What are your personal limitations?
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