Intake Form

Full name

Gender Identity

Name of parent/guardian (if you are under 18)

Birthdate

Age

Local Address

Phone

May I leave a message? May I leave a message? Yes No

May I send a text? May I send a text? Yes No

Email

May I send you an email? May I send you an email? Yes No

Have you had previous counseling? Have you had previous counseling? Yes No

If yes, when? Please list name of therapist and duration.

Previous diagnosis (if known)

Are you currently taking any medications? If yes, please list:

Please list any persistent physical symptoms or health concerns:

Do you exercise? Do you exercise? Yes No

Preferred form of exercise?

Do you drink alcohol? Do you drink alcohol? Yes No

Have you ever tried to quit? Have you ever tried to quit? Yes No

If yes, for how long did you abstain?

Have you had suicidal thoughts recently? Have you had suicidal thoughts recently? Yes No

Have you had them in the past? Have you had them in the past? Yes No

Are you currently in a relationship? Are you currently in a relationship? Yes No

If yes, on a scale from 1 – 10, how would you rate the quality of this relationship?

In the last year have you experienced any significant life changes or stressors? Please list:

Please check if you have experienced in the last month: Please check if you have experienced in the last month: Depressed mood Anxious mood Panic Irritability Low self- esteem Angry outbursts Difficulty concentrating Repetitive thought or behaviors Feeling powerless Lower libido Excessive worry Crying spells Disorganized Withdrawal from others Lack of energy Loss of interests in activities Feeling sad, down or blue Difficulty with daily tasks Social Anxiety Over/Under eating Trouble sleeping Jumpy – high startle response Feeling lost or empty Thoughts of harming self or others Negative thoughts Feeling hopeless Self- critical Guilt

Are you currently employed? Are you currently employed? Yes No

How many hours per week?

Please explain any work-related stressors:

Were you raised with a particular Faith tradition?

Do you consider yourself to be Spiritual?

List parents and siblings and their birthdates. Please note if deceased.

Family Mental Health History. Please check if any family members have history of: Family Mental Health History. Please check if any family members have history of: Depression Bipolar Disorder Anxiety Eating Disorders Suicide Trauma Perfectionism Domestic Violence Addiction/ chemical dependency

What do you consider some of your strengths?

What do you consider some of your weaknesses?

What are your goals for counseling?