Psychotherapy Intake Form
We kindly ask your cooperation in answering the following questions below as accurate as possible since they will assist your counselor in assessing your needs pre-appointment. All information given will be kept confidential.
Client Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Gender
Please Select
Male
Female
Age
Birth Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship
What is you relationship status?
Married
Never Married
Separated
Domestic Partnership
Widowed
Other
How would you rate your relationship well-being?
Not Functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not Functioning, 10 is No Problems
Employment
What is your employment status?
Employed
Unemployed
Retired
Self-employed
Disabled
Student
Homemaker
Other
Your avg. monthly income in USD
USD
How well are you doing your job?
Not working
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not working, 10 is No Problems
Is there anything stressful about your current work?
Family & Household
Including yourself, how many people live in your household?
Total household monthly income in USD
USD
Please indicate if there is a family history of any of the following conditions;
Rows
Yes
No
Indicate Family Member
Anxiety
1
2
Depression
3
4
Substance Abuse / Alcohol
5
6
Arrested
7
8
Obesity
9
10
Schizophrenia
11
12
Suicide Attempt
13
14
Domestic Violence
15
16
Additional Comments
How would you rate your family relationship?
Not functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not functioning, 10 is No Problems
History
Have you previously received any type of mental health services?
Yes
No
Please list your previous therapist(s)
Are you currently on psychiatric medication?
Yes
No
Please list psychiatric medicines that you took or are taking currently;
General Health Information
How would you rate your physical health condition?
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
How often do you exercise?
None
1
2
3
4
5
6
7
8
9
Very Often
10
1 is None, 10 is Very Often
How would you describe your general appetite?
Very Poor
1
2
3
4
5
6
7
8
9
Very Hungry
10
1 is Very Poor, 10 is Very Hungry
How would you describe your stress level throughout the day?
Very Relaxed
1
2
3
4
5
6
7
8
9
Very Stressed
10
1 is Very Relaxed, 10 is Very Stressed
How would you rate your general happiness and well-being?
1
2
3
4
5
Symptoms
Please answer all of the statements below that describe your concerns
I often experience;
fear of many things
guilt
panic attacks
avoiding people
having nightmares
anxiety, nervousness
discomfort in social situations
sexual issues
Other
I often have;
suicidal thoughts
memory problems
sleeping disorder
struggled to explain myself to others
obsessive thoughts
violent thoughts
stress and tension
medical concerns
fatigue
work problems
Other
I often feel;
lonely
empty
sad
hopeless about the future
excessive guilt
suspicious
Other
Appointment
Please check your available times for a weekly appointment? (Check as many as applies)
Rows
Monday
Tuesday
Wednesday
Thursday
Friday
9:00am - 10.00am
17
18
19
20
21
10:00am - 11.00am
22
23
24
25
26
11:00am - 12.00pm
27
28
29
30
31
13.00pm - 14.00pm
32
33
34
35
36
14.00pm - 15.00pm
37
38
39
40
41
15.00pm - 16.00pm
42
43
44
45
46
16.00pm - 17.00pm
47
48
49
50
51
17.00pm - 18.00pm
52
53
54
55
56
18.00pm - 19.00pm
57
58
59
60
61
Please book an available time for your first appointment?
Submit
Should be Empty: