Psychotherapy Intake Assessment Questionnaire
Please complete this assessment to help us better understand your needs and experiences. Your responses will guide your initial session.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What brings you to therapy at this time?
*
How would you rate your current overall mood?
*
1
2
3
4
5
Which of the following best describe your primary concerns?
*
Anxiety
Depression or low mood
Relationship issues
Stress or overwhelm
Grief or loss
Self-esteem
Trauma
Other
Please rate the following aspects of your well-being over the past two weeks.
*
Rows
Not at all
A little
Moderately
Quite a bit
Extremely
Feeling nervous, anxious, or on edge
1
2
3
4
5
Feeling down, depressed, or hopeless
6
7
8
9
10
Difficulty relaxing
11
12
13
14
15
Trouble sleeping
16
17
18
19
20
Difficulty concentrating
21
22
23
24
25
Have you previously attended therapy or counseling?
*
Yes
No
How would you describe your current support system?
*
Please Select
Strong and supportive
Adequate
Limited
None
Preferred days/times for appointments (select all that apply)
Weekday mornings
Weekday afternoons
Weekday evenings
Saturday
Sunday
Other
Submit Assessment
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