Intake Information Form

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Martial Status

Pertinent Family Information

Cell Phone

OK to leave a message? (copy)

Home Phone

OK to leave a message?

Other Phone

OK to leave a message?

Email *

Referred By

Have you ever had any mental health services in the past or are you currently receiving mental health care?

Have you ever taken psychotropic medications? If so, are you currently taking any? What medications?

Are you experiencing any specific health difficulties at this time?

How is your sleep?

How many hours do you average per night?

How active are you?

What types of activities do you do?

How often?

Are you coming to counseling due to sadness, grief or depression?

How long have you felt this way?

Have you experience a loss recently?

Are you coming to counseling for anxiety or panic attacks?

Have you recently had any significant changes or stressful events in your life?

What is your current employment status

Do you enjoy your work? What are the significant stressors associated with your work?

What are some of your strengths?

What do you hope to gain from this counseling experience?

What else would you like me to know at this point that has not been included on this questionnaire?