Click Here to Download The Client Intake Form
CLIENT INFORMATION FORM
Today’s date: _______________ Date of birth: __________________
Your name: ___________________________________________________________________
Home street address: _________________________________________________
City: _____________________________ State: _______Zip:__________________
Name of Employer:___________________________________________________________
Address of Employer: ______________________________________________________________
City: ______________________________ State: ______Zip:__________________
Cell: ________________ Work: ________________
Home: _____________ Email: ____________________
Calls will be discreet, but please indicate any restrictions: __________________________________________________
Referred by: ________________________________________________
– May I have your permission to thank this person for the referral? Yes No
If referred by another clinician, would you like for us to communicate with one another? Yes No
Person(s) to notify in case of any emergency: _______________________________
I will only contact this person if I believe it is a life or death emergency. Please provide your signature to indicate that I may do so: (Your Signature): _____________________________
Please briefly describe your presenting concern(s): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are your goals for therapy? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How long do you expect to be in therapy in order to accomplish these goals (or at least feel like you have the tools to accomplish them on your own)? ________________________________________________________________________________________**The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.**
MEDICAL HISTORY:
Please explain any significant medical problems, symptoms, or illnesses: ________________________________________________________________________________________________________________________________________________________________________________________________
Current Medications:
Name of Medication Dosage Purpose Doctor
________________________________________________________________________________________________________________________________________________
Do you smoke or use tobacco? YES NO If YES, how much per day?___________________
Do you consume caffeine? YES NO If YES, how much per day? ___________________
Do you drink alcohol? YES NO If YES, how much per day/week/month/year? ______________________________________________
Do you use any non-prescription drugs? YES NO
If YES, what kinds and how often? ___________________________________________
Have any of your friends or family members voiced concern about your substance use? YES NO
Have you ever been in trouble or in risky situations because of your substance use? YES NO
Previous medical hospitalizations (Approximate dates and reasons):__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Previous psychiatric hospitalizations (Approximate dates and reasons):__________________________________________________________________________________________________________________________________________
Have you ever talked with a psychiatrist, psychologist, or other mental health professional? YES NO (Please list approximate dates and reasons): ________________________________________________________________________________________________________________________________________________
Height ____ Weight _______ Age______ Gender ________
Sexual & Gender Identity: __ Heterosexual __Lesbian __Gay __Bisexual __Transgender __ Asexual __ In Question __Other: _________________
Racial/Ethnic Identity:
__African/African-American/Black __ Latino/Latino-American
__Bi-Racial/Multi-Racial __American Indian/Alaska Native
__ Middle Eastern/Middle Eastern-American
__Asian/Asian-American/Asian Pacific Islander __White/European-American __Not listed
FAMILY:
How would you describe your relationship with your mother?________________________________________________________________________________________________________________________________________________
How would you describe your relationship with your father?________________________________________________________________________________________________________________________________________________
Are your parents still married?____ If they divorced, how old were you when they separated or divorced, and how did this impact you? ________________________________________________________________________________________________________________________________________________
Were there any other primary care givers who you had a significant relationship with? If so, please describe how this person may have impacted your life: ________________________________________________________________________________________________________________________________________________
How many sisters do you have? ______ Ages? _______________
How many brothers do you have? ______ Ages? ______________
How would you describe your relationships with your siblings? ________________________________________________________________________________________________________________________________________________
RELATIONSHIPS & SOCIAL SUPPORT & SELF-CARE: Currently in Relationship? ____ How Long? ____
Poor Excellant
Relationship Satisfaction: 1 2 3 4 5 6 7
Married/Life Partnered? _____ How Long? ____ Previously Married/Life Partnered? YES NO
If so, length of previous marriages/committed partnerships_______________________________________
Do you have Children?____ If YES, how many and what are their ages:_____________________________________________
Describe any problems any of your children are having: ________________________________________________________________________________________________________________________________________________Whose living in your household: ________________________________________________________________________________________________
Please briefly describe any history of abuse, neglect and/or trauma: _______________________________________________________________________________________________________________________________
Current level of satisfaction with your friends and social support:
POOR EXCELLENT
1 2 3 4 5 6 7
Please briefly describe your coping mechanisms:_______________________________________________________________________________________________________________________________________
Is spirituality important in your life and if so please explain:___________________________________________________________________________________________
Briefly describe your diet and exercise patterns:__________________________________________________________________________________________
EDUCATION & CAREER
High School/GED___ College Degree___ Graduate Degree(or Higher)___ Vocational Degree___
What is your current employment?________________________________________________________________________________________________
POOR EXCELLENT
Employment Satisfaction: 1 2 3 4 5 6 7
Any past career positions that you feel are relevant?________________________________________________________________________________________________
What do you think are your strengths?________________________________________________________________________________________________
PLEASE CHECK ALL THAT APPLY & CIRCLE THE MAIN PROBLEM:
DIFFICULTY WITH: NOW/IN THE PAST
Anxiety People in General Nausea
Depression Parents Abdominal Distress
Mood Changes Children Fainting
Anger or Temper Marriage/Partnership Dizziness
Panic Friend(s) Diarrhea
Fears Co-Worker(s) Shortness of Breath
Irritability Employer Chest Pain
Concentration Finances Lump in the Throat
Headaches Legal Problems Sweating
Loss of Memory Sexual Concerns Heart Palpitations
Excessive Worry History of Child Abuse Muscle Tension
Feeling Manic History of Sexual Abuse Pain in joints
Trusting Others Domestic Violence Allergies
Communicating Thoughts of Hurting Often Make Careless
with Others Someone Else Mistakes
Drugs Hurting Self Fidget Frequently
Alcohol Thoughts of Suicide Speak Without Thinking
Caffeine Sleeping Too Much Waiting Your Turn
Frequent Vomiting Sleeping Too Little Completing Tasks
Eating Problems Getting to Sleep Paying Attention
Severe Weight Gain Waking Too Early Easily Distracted by Noises
Severe Weight Loss Nightmares Hyperactivity
Blackouts Head Injury Chills or Hot Flashes
FAMILY HISTORY OF (Check all that apply):
Drug/Alcohol Problems Physical Abuse Depression
Legal Trouble Sexual Abuse Anxiety
Domestic Violence Hyperactivity Psychiatric Hospitalization
Suicide Learning Disabilities “Nervous Breakdown”
Any additional information you would like to include: ________________________________________________________________________________________________________________________________________________________________________________