Intake Form Professional Counseling

Name of Therapist

Name:

Date:

Address:

Home Phone:

Cell/Work/Other Phone:

Email Address:

Please check your email address for errors

*Please note: Email Correspondence is not considered to be confidential medium of communication.

Parent/Legal Guardian (if under 18):

DOB:

Age:

Gender: M F

Marital Status: Never Married Domestic Partnership Married Separated Divorced Widowed

Referred By (if any):

History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? No Yes

Previous Therapist/Practitioner:

Are you currently taking any prescription medication? No Yes

If yes, please list:

Have you ever been prescribed psychiatric medication? No Yes

If yes, please list and provide dates:

General and Mental Health Information

1. How would you rate your current physical health? (Please select one) Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific health problems you are currently experiencing:

2. How would you rate your current sleep habits? Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing:

3. How many times per week do you generally exercise?

What types of exercise do you participate in?

4. Please list any difficulties you experience with your appetite or eating problems:

5. Are you currently experiencing overwhelming sadness, grief, or depression? No Yes

If yes, for approximately how long?

6. Are you currently experiencing anxiety, panic attacks or have any phobias? No Yes

If yes, when did you begin experiencing this?

7. Are you currently experiencing any chronic pain? No Yes

If yes, please describe:

8. Do you drink alcohol more than once a week? No Yes

9. How often do you engage in recreational drug use? Daily Weekly Monthly Infrequently Never

10. Are you currently in a romantic relationship? No Yes

If yes, for how long?

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?

11. What significant life changes or stressful events have you experienced recently?

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 (e.g. father, grandmother, uncle, etc.)

Alcohol/Substance Abuse Yes No

List Family Member:

Anxiety Yes No

List Family Member:

Depression Yes No

List Family Member:

Domestic Violence Yes No

List Family Member:

Eating Disorders Yes No

List Family Member:

Obesity Yes No

List Family Member:

Obsessive Compulsive Behavior Yes No

List Family Member:

Schizophrenia Yes No

List Family Member:

Suicide Attempts Yes No

List Family Member:

Additional Information

1. Are you currently employed? No Yes

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

2. Do you consider yourself to be spiritual or religious? No Yes

If yes, describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

5. What would you like to accomplish out of your time in therapy?

By clicking the submit button you acknowledge that you have read and agree to the terms in our Privacy Policy.

Professional Counseling Online Intake Form

History

General and Mental Health Information

Family Mental Health History

Additional Information