New Client Intake

 
Please provide the following information and answer the questions below. Please note: Information you provide here is protected as confidential information.
Please complete this form prior to your first session.
Name *
Name
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
Relationship Status *
Highlest Level of Education Completed *
Have You Previously Received Any Type of Mental Health Services (Psychotherapy, Psychiatric Services, Etc.)? *
Are You Currently Taking Any Prescription Medication? *
Have You Ever Been Prescribed Psychiatric Medication? *
GENERAL HEALTH AND MENTAL HEALTH INFORMATION:
How Would You Rate Your Current Physical Health? *
How Would You Rate Your Current Sleeping Habits? *
How Many Times Per Week Do You Generally Exercise? *
Are You Currently Experiencing Any Difficulties With Your Appetite or Eating Patterns? *
Are You Currently Experiencing Overwhelming Sadness, Grief or Depression? *
Are You Currently Experiencing Anxiety, Panic Attacks or Have Any Phobias? *
Are You Currently Experiencing Any Chronic Pain? *
Do You Currently Drink Alcohol More Than Once A Week? *
How Often Do You Engage In Recreational Drug Use? *
Are You Currently In A Romantic Relationship? *
FAMILY MENTAL HEALTH HISTORY:
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 (Mother, Father, Grandmother, Uncle, Etc.).
Alcohol/Substance Abuse *
Anxiety *
Depression *
Domestic Violence *
Eating Disorders *
Obesity *
Obsessive-Compulsive Disorder *
Schizophrenia *
Suicide Attempts *
ADDITIONAL INFORMATION:
Are You Currently Employed? *
Do You Consider Yourself To Be Religious or Spiritual? *
Today's Date *
Today's Date