CLIENT INTAKE
Personal Information
Full Name: ____________________________________________________ Date:__________
I prefer to be called: ___________________________________ Age: ______ D.O.B.:________
Residential Address:_____________________________________________________________
______________________________________________________________________________
Please list all of the phone numbers where we may call you:
Home Phone: ______________________ May we leave a message? Yes/No
Cell Phone: ________________________ May we leave a message? Yes/No
Work Phone: _______________________ May we leave a message? Yes/No
E-mail: ________________________ May we send you occasional e-mails regarding articles,
books, resources, and events which may benefit you? (You can unsubscribe at any time) ? Y/N
Referred by?: __________________________________________________________________
In case of emergency, please notify: Name: __________________________________________
Phone: _________________ Relationship:___________________________________________
Marital Status: ___ Never Married ___ Domestic Partnership ___Married
___Separated ___Divorced ___ Widowed
Are you currently in a romantic relationship: ___Yes ___No
Previous marriages/long-term partnerships:
Length(s) of relationship(s): ____________________________ When ended: _______________
Reason: (widowed, divorced, etc.) __________________________________________________
Education
School has been: ___ Easy ___ Fairly Easy ___ Difficult ___ Very Difficult
Areas of achievement: ___________________________________________________________
Specific area(s) of difficulty: _______________________________________________________
Occupation
Are you currently employed? ___ Yes __ No
If yes, what is your current occupation? _____________________________________________
Do you enjoy your work? ___ Yes ___ No
Please list any work-related stressors, if applicable: ____________________________________
______________________________________________________________________________
Has your employer/supervisor ever expressed any of these concerns? (Check all that apply)
___ Missing too much work
___ Late too often
___ Increased errors
___ Irresponsibility
___ Poor/bad attitude ___ Difficulty getting along with other workers/supervisors
Other_________________________________________________________________________
Health
Physical Condition: ___ Excellent ___ Good ___ Fair ___ Poor
Do you have a physical fitness program? ___ Not at all ___ Occasionally ___ Regularly
Please list any significant illnesses, including allergies: ____________________________
Have you experienced any significant weight change in the last 2 months? ___ Yes ___ No
If yes, please specify: _________________________________________________________
Are you having any difficulty with appetite or eating habits? ___ Yes ___ No
If yes, please check where applicable: ___ Eating Less ___ Eating More ___ Bingeing
___Restricting ___ Purging Other: ________________________________________________
Are you having any problems with your sleep habits? ___ Yes ___ No
If yes, check where applicable: ___ Difficulty falling asleep___ Insomnia ___ Sleeping too much
___ Poor Quality Sleep ___ Early morning waking ___ Disturbing dreams ___ Night terrors
Please list any prescription and over-the-counter medications/supplements, including dosages
if known: ______________________________________________________________________
______________________________________________________________________________
Please list any persistent physical symptoms or health concerns: (e.g. chronic pain, headaches,
hypertension, diabetes, etc.)______________________________________________________
Do you have any current or past history of addictive behavior? (e.g. drinking, drugs, gambling,
etc.)__________________________________________________________________________
Do you drink alcohol? ___ Yes ___ No If yes, how much? ______________________________
Do you use other substances? ___ Yes ___ No If yes, which substances/how much? ________
______________________________________________________________________________
Have you ever received treatment for alcohol/drug use? ____ Yes ___ No Please specify: ____
______________________________________________________________________________
Do you now or have you ever attended a 12 step group? (AA, NA, ALANON, GA, etc.) ___ Yes
___ No If yes, please specify: ____________________________________________________
Are you currently experiencing anxiety, panic attacks or have any phobias? If yes, please
elaborate, including when you began to experience these symptoms. _____________________
______________________________________________________________________________
Are you currently receiving psychiatric services, professional counseling, or psychotherapy
elsewhere? ___ Yes ___ No If yes, please specify: ____________________________________
Counseling History: ___ No previous treatment ___ Previous outpatient treatment ___ Previous
Hospitalization
Are you currently experiencing overwhelming sadness, grief, or depression? If yes, for
approximately how long? _________________________________________________________
What significant life changes or stressful events have you experienced recently? ____________
______________________________________________________________________________
What significant life changes or stressful events have you experienced in the past? __________
What is your current level of stress? ________________________________________________
Do you experience severe emotional and mood changes to the point where they make it
difficult to function at your normal level? ___ Never ___ Seldom ___ Often
Check which kind(s): ___ Anxiety ___ Manic states ___ Anger ___ Depression
Have you ever had suicidal thoughts? ___ Never ___ Seldom ___ Often
Have you ever attempted suicide? ___ Yes ___ No If yes, please explain: ___________________
______________________________________________________________________________
Do you have any history of self-harm? ___ Yes ___ No If yes, please describe: ______________
______________________________________________________________________________
How satisfied are you with your friendships and sense of support from others? _____________
______________________________________________________________________________
What hobbies or interests do you enjoy? ____________________________________________
What do you consider some of your strengths? _______________________________________
What do you consider some of your weaknesses? _____________________________________
What do you like most about yourself? ______________________________________________
What do you like least about yourself? ______________________________________________
Do you consider yourself to be spiritual or religious? ___ Yes ___ No If yes, please describe
your faith or belief system: _______________________________________________________
Do you have a system of saving money? ___ Yes ___ No
Are you currently, or have you ever been, in a financial crisis? ___ Yes ___ No If yes, please
specify: _______________________________________________________________________
Please list your reasons for counseling at this time: ____________________________________
______________________________________________________________________________
What do you hope to accomplish in therapy? _________________________________________
______________________________________________________________________________
What do you want to change about yourself in counseling? _____________________________
Family History
Mother: Name_______________________________ Age_____ (If deceased, when?)________
Nationality_________________________ Highest level of education______________________
Occupation____________________ Abilities/special interests____________________________
General Health Status: Physical___________________ Emotional_________________________
Describe your relationship with her: ________________________________________________
Father: Name_______________________________ Age_____ (If deceased, when?)_________
Nationality: ___________________________Highest level of education____________________
Occupation: ___________________________ Abilities/special interests____________________
General Health Status: Physical ____________________Emotional:_______________________
Describe your relationship with him:________________________________________________
Number of Brothers: ______ Number of Sisters: ______ Name/Age/Occupation ___________
______________________________________________________________________________
______________________________________________________________________________
With whom did you live during your childhood? (Check all that apply)
___Mother & Father ___ Mother only ___ Father only ___ Mother & Stepfather
___ Father & Stepmother ___ Relatives ___ Foster Parents Other_____________________
Describe your childhood (infancy through age 12): ___ Very Happy ___ Pleasant
___ Bearable ___ Unhappy
Please explain: _________________________________________________________________
______________________________________________________________________________
Describe your adolescence (ages 12 through 21): ___ Happy ___Unhappy ___ Mixed
Please explain: ________________________________________________________________
_____________________________________________________________________________
Check all that apply: ___I was not abused as a child ___I witnessed abuse in the home
___I was emotionally abused ___I was physically abused ___I was sexually abused as a child
Please explain:
______________________________________________________________________________
______________________________________________________________________________
Any family history of alcohol and/or drug abuse: ____ Who? ___________________________
Have any of your family members ever received counseling? ___ yes ___no If yes, who and
for what reason?________________________________________________________________
______________________________________________________________________________
Growing up in your family, were there any major crisis events: sicknesses; deaths;
relocations; traumas; shameful happenings? Briefly describe:___________________________
______________________________________________________________________________
In order for a family to be healthy or close, that family must… (Please fill in the blank): ______
______________________________________________________________________________
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.)
_Please Circle_________________List Family Member_____________
Alcohol/Substance Abuse
ADD/ADHD
Anxiety Disorder
Adoption
Bipolar Disorder
Depression
Domestic Violence
Eating Disorder
Learning Disabilities
Obesity
Obsessive Compulsive Behavior
Panic Attacks
Schizophrenia
Sleep Disturbances
Suicide Attempts
Trauma History
Please circle all of the issues which apply to you:
Insomnia
Memory
Concentration
Anger
Stress
Loneliness
Drug use
Anxiety
Alcohol use
Friends
Family
Fears
Appetite
Shyness
Suicidal thoughts
Phobias
Mood swings
Rapid speech
Panic attacks
Hallucinations
Unexplained losses of time
Depression
Eating disorder
Body image problems
Self-control
Health problems
Sexual problems
Legal matters
Repetitive thoughts
Repetitive behaviors
Making decisions
Homicidal thoughts
Stomach problems
Addiction
Relationship Difficulties
Self-esteem issues
Cutting
Grief over a loss
Post abortion grief
Other: _____________________________________________________________________