Therapy Intake Form

Name*
First Last
Gender*
Age
Birthdate*
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Best phone number to reach you*
May I leave voice messages?
- Yes
- No
Your Email*
Enter Email Confirm Email
Emergency Contact
Relationship
Emergency Contact Phone

000-000-0000
Sexual Orientation
Relationship Status
Ethnic Background
Religion
Education Level
Occupation
Current Issues
Please provide a brief description of why you are seeking counseling/therapy services at this time:
Has anything happened that may have brought on/intensified the problems you are experiencing?
- No Answer
- Yes
- No
If yes, please explain:
When (month/year) did you first begin to experience these problems?
How much is/are the problems affecting you?
In what areas do your problems impact your life? (check all that apply)
- Lifestyle (the way you live your life)
- Activities (things you normally do or would like to do)
- Relationships (your ability to form or maintain relationships with others)
- Eating
- Shopping
- Mood
Have you ever attempted suicide?
- No answer
- Yes
- No
If so, when?
Have you been thinking about suicide?
- No answer
- Yes
- No
Have you been thinking about harming or killing someone else?
- No answer
- Yes
- No
Adult Problems Checklist
Please check all that apply:
- Depression
- Low energy
- Low self-esteem
- Poor concentration
- Lack of interest/enjoyment in life
- Feeling hopeless
- Feeling worthless
- Feeling guilty or shameful
- Sleep changes (more/less)
- Loneliness
- Bad dreams/nightmares
- Feeling ignored or abandoned
- Appetite changes (more/less)
- Mood swings
- Thoughts of hurting self
- Thoughts of hurting others
- Isolating from others/social withdrawal
- Feelings of sadness/loss
- Weight problems
- Stress
- Anxiety/tension/worry
- Panic attacks
- Heart racing
- Chest pain or heaviness
- Chills/hot flashes
- Tingling/numbness
- Pain
- Fear of dying
- Fear of going “crazy”
- Nausea
- Fears or phobias
- Obsessions or compulsions
- Thoughts racing
- Disorganization
- Procrastination
- Can’t hold onto an idea
- Anger/frustration
- Suspiciousness or mistrustfulness
- Problems trusting others
- Easily irritated/annoyed
- Aggressiveness
- Perfectionist behavior
- Lying
- Making/keeping friends
- Arguing with others
- Performing unusual rituals or habits
- Impulsiveness
- Excessive behaviors (examples: spending, gambling)
- Delusions/hallucinations (thinking/believing or seeing/hearing unusual things)
- Sexual problems
- Self injurious behaviors
- Shyness
- Social skills
- Social support (family/friends)
- Stealing
- Strange, weird, or peculiar behavior
- Confusion/can’t think clearly
- Feeling “not real”
- Feeling detached from yourself
- Feeling “hyper”
- Financial problems
- Grief/bereavement
- Health problems
- Impact of your problems on others
- Losing track of time
- Problems with memory
- Unpleasant thoughts that won’t go away
- Bothered by recurring thoughts
- Job/career problems or indecision
- Destruction of property
- Self-criticism
- Family problems
- Marital/relationship problems
- Parent/child problems
- Use of alcohol
- Use of drugs
- Blackouts
- Physical abuse
- Sexual abuse
- Partner abuse
- Trouble with the law
- Experienced/witnessed trauma
- Loss/death of someone close
- Other
Describe "Other" (if checked)
Mood
What has been your most prevalent mood for the last three weeks?
Sleep
On average how many hours of sleep do you get a night?
Do you sleep through the night and wake feeling rested?
- No Answer
- Yes
- No
If no, please explain:
Do you remember your dreams?
- No Answer
- Yes
- No
If yes, please explain:
Do you have nightmares?
- No Answer
- Yes
- No
If yes, please explain:
Appetite
What do you typically eat during your day?
When are you most likely to skip a meal, and how do you think you benefit from it?
Under what circumstances are you most likely to comfort yourself with food?
Exercise
What do you do for exercise?
On average how often do you exercise per day, week, or month? For how long?
What are your reasons for exercising?
Energy
What is your energy like day to day?
- No Answer
- I have more than enough energy to get through the day
- I have enough energy to get through the day
- Neutral
- I have some energy, but not enough energy to get through the day
- I have little to no energy to get through the day
How is your motivation?
- No Answer
- Excellent
- Good
- Neutral
- Somewhat Poor
- Poor
Current Life Experiences
I live in:
- No Answer
- Apartment
- House
- Condo/Townhouse
- Mobile Home
- Rooming House
Name and age of person/people I live with, and their relationship to me:
Problems I'm facing:
My sources of satisfaction:
My sources of stress:
My leisure activities:
My current life goals:
What I hope to gain from counseling/therapy:
History of Current Counseling/Therapy
Are you currently being treated by a counselor, psychologist, psychiatrist, and/or other physician for the problems noted above?
- No answer
- Yes
- No
Please list professionals you are currently seeing for treatment:
You may add as many lines as needed by clicking on the "plus" sign to the right of each line.
Date Name Address Treatment Type
What is helpful and working for you in your current therapy experience?
What is unhelpful and not working for you in your current therapy experience?
History of Past Counseling/Therapy
Have you ever been treated by a counselor, psychologist, psychiatrist, and/or other physician in the past?
- No answer
- Yes
- No
Please provide information regarding previous treatment you have received from a counselor, psychologist, psychiatrist, or other medical or mental health professional for this or other problems:
You may add as many lines as needed by clicking on the "plus" sign to the right of each line.
Date Name Address Treatment Type Why Treatment Ended
What helped and worked for you previously in therapy?
What was unhelpful and didn’t work for you previously in therapy?
History of Hospitalizations
Have you ever been hospitalized for treatment of an emotional or mental disorder?
- No answer
- Yes
- No
Please list the following information for each hospitalization:
You may add as many lines as needed by clicking on the "plus" sign to the right of each line.
Date Hospital/Facility Name Address
If yes, please explain:
History of Current & Past Medical Conditions
Please list current and past medical conditions and treatment:
You may add as many lines as needed by clicking on the "plus" sign to the right of each line.
Date Condition Treatment Results Physician Name Physician Addresss
History of Current Prescriptions & Medications
Please list all current prescription and over the counter medication use:
You may add as many lines as needed by clicking on the "plus" sign to the right of each line.
Start Date Medication Dose Frequency Condition Treated
History of Past Prescriptions & Medications
Please list any previous prescription and over the counter medication use significant to your counseling/therapy:
You may add as many lines as needed by clicking on the "plus" sign to the right of each line.
Start Date End Date Medication Dose Frequency Condition Treated
History of Current & Past Substance Use
Please list any current or previous use of street drugs, tobacco products, or alcohol:
You may add as many lines as needed by clicking on the "plus" sign to the right of each line.
Start Date End Date Type Used Frequency Amount Used Comment
One Final Thing:
Is there anything else that you feel is important for me to know?
- No Answer
- Yes
- No
If yes, please explain:
Please carefully read the statement below
By signing below I am consenting to receive counseling services. I understand that I am responsible for all fees for services provided to me at the time of receiving services. I agree to the late cancellation/no show policy of paying the full fee for a session if I do not cancel or reschedule 24 hours in advance. I have read and understand my rights and the limits of confidentiality, privacy, and my rights as explained in the documents Consent to Treatment and Notice of Privacy Practices for Protected Health Information
Date
MM slash DD slash YYYY
Full Name*
First Middle Last
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Date	Name	Address	Treatment Type

Date	Name	Address	Treatment Type	Why Treatment Ended

Date	Hospital/Facility Name	Address

Date	Condition	Treatment	Results	Physician Name	Physician Addresss

Current Issues

Adult Problems Checklist

Mood

Sleep

Appetite

Exercise

Energy

Current Life Experiences

History of Current Counseling/Therapy

History of Past Counseling/Therapy

History of Hospitalizations

History of Current & Past Medical Conditions

History of Current Prescriptions & Medications

History of Past Prescriptions & Medications

History of Current & Past Substance Use

One Final Thing:

Please carefully read the statement below