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Catherine LeBlanc, MFT #MFC49504 717 7th Street Davis, CA 95616 (530) 574-7779 (530) 341-0614 fax catherineleblancmft@gmail.com www.catherineleblancmft.com Intake Questionnaire General: Name _________________________________ Date__________________________ Age __________________________________ Date of birth ___________________ Address _______________________________ Cell/Home Phone _______________ Work phone ___________________________ Fax __________________________ E-mail ________________________________ Referred by ____________________ Occupation_____________________________ Employer______________________ Educational level________________________ Employer Address_______________ Relationship status ______________________ Partner’s Name _________________ Social Security Number: _________________ Occupation ____________________ Names and ages of Children: _______________________________________________ _______________________________________________________________________ Any other members of your household? _______________________________________ Emergency contact information ______________________________________________ What is the best way for me to contact you? Are there any numbers I should not use to leave messages?__________________________________________________________ Financial Information: How do you intend to pay for treatment? (cash, check, charge, insurance) ___________ If planning to use health insurance: Name of insurance company ________________________________________________ Name of Primary Insured___________________________________________________ Primary Insured’s Social Security Number_____________________________________ Primary Insured’s Birth Date________________________________________________ Primary Insured’s Employer_________________________________________________ Policy # ______________________________ Group # ___________________________ Telephone Number and Address of Insurance Company: ________________________________________________________________________ Subscriber #__________________ Authorization #______________________________ Is there secondary insurance? If so, fill out the following: Name of insurance company ________________________________________________ Name of Secondary Insured_________________________________________________ Secondary Insured’s Social Security Number___________________________________ Secondary Insured’s Birth Date______________________________________________ Secondary Insured’s Employer_______________________________________________ Policy # ______________________________ Group # ___________________________ Telephone Number and Address of Insurance Company: ________________________________________________________________________ Subscriber #__________________ Authorization #______________________________ Areas of Concern Please write “P” or “C” for past or current/recent symptoms: ____Headaches ____Sadness ____Anger ____Dizziness ____Obsessions ____Aggression ____Fainting ____Compulsions ____Relationship Issues ____Nausea ____Loneliness ____Isolation ____Decreased Appetite ____Racing Thoughts ____Hopelessness ____Increased Appetite ____Sexual Dysfunction ____Hyperactivity ____Fatigue ____Frequent Urination ____Impulsivity ____Insomnia ____Bowel Disturbance ____Elevated Mood ____Increased Sleep ____Hallucinations ____Mood Swings ____Nightmares ____Paranoia ____Hearing Voices ____Anxiety ____Allergies ____Trauma ____Panic Attacks ____Anorexia/Purging ____Tics ____Suicidal Thoughts ____Suicidal Actions ____Homicidal Thoughts ____Feel Like Crying ____Can’t Keep Friends ____Feel Tense ____Distrust of Others ____Financial Problems ____Lack of Interest ____Feel Worthless ____Blurred Vision ____Flashbacks ____Stomach Trouble ____ Conflict Within Family ____ Always Tired ____Recent Weight Gain/Loss ____Excessive Checking, List-Making, Washing ____Smelling Things Others Don’t Smell ____Decreased Need for Sleep ____Verbal, Emotional, Physical, Sexual Abuse _____Victim of Violent Crime Do you have any other conditions or symptoms it would be important for me to know about you? ______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Do you have any specific goals with regard to your treatment? Any concerns about treatment? _______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Psychological History Have you ever received mental health treatment before? __________________________ When and for how long? ___________________________________________________ What was the focus of treatment? ____________________________________________ What are some individual or relational problem areas for you?______________________ ________________________________________________________________________ ________________________________________________________________________ How have you attempted to deal with them in the past? Were your efforts successful?______________________________________________________________ ________________________________________________________________________ Have you ever undergone psychological testing? ________________________________ If so, by whom? __________________________________________________________ Have you ever been hospitalized for mental or emotional problems? _________________ When and for how long? ___________________________________________________ Why were you hospitalized? ________________________________________________ Name of treating hospitals, doctors, therapists, addresses, telephone numbers (I will not contact these therapists without your written authorization): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Are you currently taking any prescription medications? ___________________________ Name of prescribing doctors, addresses, telephone numbers (I will not contact these doctors without your written authorization): _________________________________ _______________________________________________________________________ _______________________________________________________________________ How long have you been on the medications? ___________________________________ Have you ever taken any medications for a mental or emotional condition? ___________ When and for how long? ___________________________________________________ _______________________________________________________________________ Have you ever attempted suicide? ____________________________________________ When? _________________________________________________________________ Describe the circumstances that led to that attempt. ______________________________ ________________________________________________________________________ ________________________________________________________________________ Are you currently having any suicidal thoughts? Please describe ____________________ ________________________________________________________________________ ________________________________________________________________________ Medical History Name, address, and telephone number of physician:______________________________ _______________________________________________________________________ Have you ever been diagnosed with a serious illness? Please describe_______________ ________________________________________________________________________ Do you have any medical conditions that may affect your mental health treatment? ____ ________________________________________________________________________ ________________________________________________________________________ Please describe your overall health today _____________________________________ ________________________________________________________________________ Are you experiencing any medical/physical symptoms you attribute to a mental, emotional, or stress-related condition? Please describe. __________________________ ________________________________________________________________________ Do you Smoke? And if so, how much:_________________________________________ Do you Drink Alcohol? And if so, how much/often:______________________________ Do you Take Drugs? And if so, how often and what kind:_________________________ Have you ever been in a 12-step program? Please describe. _______________________ ________________________________________________________________________ Family of Origin History Please describe your family of origin, including names and ages of family members, and your relationships with them: ______________________________________ ________________________________________________________________________ ________________________________________________________________________ Other Information Please describe your spiritual identity/orientation. ______________________________ Please describe your interests/hobbies _______________________________________ Are you now or have you ever been involved in a lawsuit? _______________________ Please describe. _________________________________________________________ ________________________________________________________________________ Please feel free to include any other information that you believe is relevant to your mental health treatment:
