Individual Intake Form

GENERAL
Name (required): Date of birth
Address:
City: State: ZIP:
Home phone: May I leave a message? YesNo
Work/Cell phone: May I leave a message? YesNo
Email: May I contact you via email? YesNo
Employer/school:
Occupation:
Emergency contact: Phone: Relationship:
Educational background:
Learning disabilities:
Religious upbringing:
Present affiliation/identification (if any):
Current living situation:
Reason for seeking counseling/therapy at this time:
What do you hope to achieve with therapy?

MEDICAL HISTORY
General health:
Are you now under a physician’s care? YesNo
If yes, reason for care:
Physician’s name: Telephone:
Medications:
Reason for medication:
Last medical examination:
Have you ever been hospitalized for a physical illness? YesNo
Describe:

Have you ever been hospitalized for a mental illness? YesNo
Describe:

Have you ever considered or attempted suicide? YesNo
If yes, please explain:

Have you ever been in a drug, alcohol or other treatment program? YesNo
If yes, please provide details:

Do you currently drink alcohol? YesNo
How much/how often:
Do you currently use recreational drugs? YesNo
How much/how often:
Do you feel you have a problem with alcohol or drugs? YesNo
Previous therapy/counseling: YesNo
If yes, describe reason, duration and outcome:

Please check any of the following struggles that pertain to you:
AnxietySexual ProblemsFinancesSelf-ControlWork/Stress
DepressionSuicidal ThoughtsDrug/Alcohol UseUnhappiness
Health ProblemsFears/PhobiasSeparation/DivorceCareer Choices
InsomniaCutting/Self-MutilationEating Disorders
RelationshipsAngerReligious MattersThought Patterns

WORK HISTORY
Occupation: How long?
If presently unemployed, describe situation:

Hobbies/avocations:

FAMILY INFORMATION
Parents and step-parents (indicate under “age” if deceased)
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation

Siblings and step-siblings (indicate under “age” if deceased)
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation

Do any of your relatives have a history of mental illness? YesNo
If yes, please explain:

Significant partner status (please select):
SingleEngagedMarriedDivorcedSeparatedLiving togetherRemarriedWidowedOther
Name of significant partner:
Children from this relationship:
Name Gender Age
Name Gender Age
Name Gender Age
Name Gender Age
Children from previous relationship:
Name Gender Age
Name Gender Age
Name Gender Age
Name Gender Age

Be Sociable, Share!