CLIENT INTAKE QUESTIONAIRE

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Please note: information provided on this form is protected as confidential information.

Personal Information

Personal Information
Name:
Parent/Legal Guardian (if under 18):
Address:
Home Phone: May we leave a message? Yes No
Cell/Work/Other: May we leave a message? Yes No
Email: May we send a message? Yes No
*Please note: Email correspondence is not considered to be a confidential medium of communication.
Date of Birth:
Age:
Gender:
Marital Status: Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed
Referred by:
What are the reasons you are seeking therapy at this time?
What significant life changes or stressful events have you experienced in the last 1 – 2 years (death, divorce, move, job change, etc.)?
How would you like to see your life change as a result of your therapy at Inner Light Counseling?
Are you currently employed? YES NO
If yes, what is your current employment situation?
Do you enjoy your work? Is there anything stressful about your current work?
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? NO YES, previous therapist/practitioner:
Are you currently taking any medical and/or psychiatric prescription medication? YES NO
If yes, please list name, dosage, & frequency:
Name of Primary Care Physician/Pediatrician?
Phone Number
Address
Name, address, phone number of child’s school counselor? (if applicable)
Name of person to be contacted in case of emergency?
Phone number:
How would you rate your current physical health? (please circle one) Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any specific health problems you are currently experiencing:
How would you rate your current sleeping habits: Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any specific sleep problems you are currently experiencing (trouble falling asleep, waking up, etc.):
Please list any difficulties you experience with your appetite or eating problems:
Are you currently experiencing overwhelming sadness, anger, grief, or depression? Yes No
If yes, for approximately how long?
Are you currently experiencing anxiety, panic attacks, or have any phobias? Yes No
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain? Yes No
If yes, please describe:
Do you drink alcohol more than once a week? Yes No
How often do you engage in recreational drug use? Daily
Weekly
Monthly
Infrequently
Never
History of allergic disorders?
Family Mental Health History
Please answer & list family member
Alcohol/Substance Abuse Yes No Family Member:
Anxiety Yes No Family Member:
Depression Yes No Family Member:
Domestic Violence Yes No Family Member:
Eating Disorders Yes No Family Member:
Obesity Yes No Family Member:
Obsessive Compulsive Behavior Yes No Family Member:
Schizophrenia Yes No Family Member:
Suicide / Suicide Attempts Yes No Family Member:
Other Yes No Family Member:
Client Signature:
(or parent/guardian if applicable)
Date