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5fbc3d17b05830538ec239c7 - Adult Intake Form

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Aiman Rashid

The client is seeking therapy due to concerns about depression and anxiety. They have a history of depression and are currently taking antidepressant medication prescribed by their primary care physician. They report experiencing suicidal thoughts sometimes in the past but not recently. Their family history includes depression in a sibling. Their goals for therapy include learning better coping strategies to manage their symptoms of depression and anxiety.

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5fbc3d17b05830538ec239c7 - Adult Intake Form

Uploaded by

Aiman Rashid
94 views6 pages
The client is seeking therapy due to concerns about depression and anxiety. They have a history of depression and are currently taking antidepressant medication prescribed by their primary care physician. They report experiencing suicidal thoughts sometimes in the past but not recently. Their family history includes depression in a sibling. Their goals for therapy include learning better coping strategies to manage their symptoms of depression and anxiety.

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5fbc3d17b05830538ec239c7_Adult Intake Form

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The client is seeking therapy due to concerns about depression and anxiety. They have a history of depression and are currently taking antidepressant medication prescribed by their primary care physician. They report experiencing suicidal thoughts sometimes in the past but not recently. Their family history includes depression in a sibling. Their goals for therapy include learning better coping strategies to manage their symptoms of depression and anxiety.

Copyright:

© All Rights Reserved
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
94 views6 pages

5fbc3d17b05830538ec239c7 - Adult Intake Form

Uploaded by

Aiman Rashid
The client is seeking therapy due to concerns about depression and anxiety. They have a history of depression and are currently taking antidepressant medication prescribed by their primary care physician. They report experiencing suicidal thoughts sometimes in the past but not recently. Their family history includes depression in a sibling. Their goals for therapy include learning better coping strategies to manage their symptoms of depression and anxiety.

Copyright:

© All Rights Reserved
Download as DOCX, PDF, TXT or read online from Scribd
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You are on page 1/ 6

CLIENT INTAKE FORM

Please provide the following information for our records. Leave blank any
question you would rather not answer, or would prefer to discuss with your
therapist. Information you provide here is held to the same standards of
confidentiality as our therapy.

PRIMARY CONCERN

Please share why you’re seeking therapy at this time:


_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

How long has this been going on?


_____________________________________________________________________
_____________________________________________________________________

Is this concern related to a known mental health diagnosis, like depression or


anxiety?
( ) no ( ) yes ( ) N/A- no mental health diagnosis

TREATMENT HISTORY

Are you currently receiving psychiatric services, professional counseling or


psychotherapy elsewhere? ( ) yes ( ) no

Have you had previous psychotherapy?


( ) no
( ) yes, with (previous therapist’s name)____________________________________

Are you currently taking prescribed psychiatric medication (antidepressants or


others)? ( ) yes ( ) no

If yes, please list: ______________________________________________________

Prescribed by: ________________________________________________________

HEALTH AND SOCIAL INFORMATION

Do you currently have a primary physician? ( ) yes ( ) no

If yes, who is it? _______________________________________________________


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Are you currently seeing more than one medical health specialist? ( ) yes ( ) no

If yes, please list: ______________________________________________________

When was your last physical? ____________________________________________

Please list any persistent physical symptoms or health concerns (e.g. chronic pain,
headaches, hypertension, diabetes, etc.:
_______________________________________

________________________________________________________________________

Are you currently on medication to manage a physical health concern? If yes, please
list: _________________________________________________________________
____________________________________________________________________

Are you having any problems with your sleep habits? ( ) yes ( ) no

If yes, check where applicable:


( ) Sleeping too little ( ) Sleeping too much ( ) Poor quality sleep
( ) Disturbing dreams( ) other _______________________________

How many times per week do you exercise? ______________

Approximately how long each time? _____________________

Are you having any difficulty with appetite or eating habits? ( ) no ( ) yes

If yes, check where applicable: ( ) Eating less ( ) Eating more ( ) Bingeing


( ) Restricting

Have you experienced significant weight change in the last 2 months? ( ) no


( ) yes

Do you regularly use alcohol? ( ) no ( ) yes

In a typical month, how often do you have 4 or more drinks in a 24 hour period?

____________________________________________________________________

How often do you engage recreational drug use? ( ) daily ( ) weekly ( ) monthly
( ) rarely ( ) never

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Do you smoke cigarettes or use other tobacco products? ( ) yes ( ) no

Have you had suicidal thoughts recently?


( ) frequently ( ) sometimes ( ) rarely ( ) never

Have you had them in the past?


( ) frequently ( ) sometimes ( ) rarely ( ) never

Are you currently in a romantic relationship? ( ) no ( ) yes

If yes, how long have you been in this relationship? _______________________

On a scale of 1-10 (10 being the highest quality), how would you rate your current
relationship? ________

In the last year, have you experienced any significant life changes or stressors? If yes,
please explain: ________________________________________________________

____________________________________________________________________

Have you ever experienced any of the following?

Extreme depressed mood Yes / No


Dramatic mood swings Yes / No
Rapid speech Yes / No
Extreme anxiety Yes / No
Panic attacks Yes / No
Phobias Yes / No
Sleep disturbances Yes / No
Hallucinations Yes / No
Unexplained losses of time Yes / No
Unexplained memory lapses Yes / No
Alcohol/substance abuse Yes / No
Frequent body complaints Yes / No
Eating disorder Yes / No
Body image problems Yes / No
Repetitive thoughts (e.g. obsessions) Yes / No
Repetitive behaviors (e.g. frequent Yes / No
checking, hand washing
Homicidal thoughts Yes / No
Suicidal attempts Yes / No If yes, when?

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OCCUPATIONAL INFORMATION

Are you currently employed? ( ) no ( ) yes

If yes, who is your current employer/position? ___________________________

If yes, are you happy with your current position? __________________________

Please list any work-related stressors, if any __________________________________

______________________________________________________________________

______________________________________________________________________

Are you currently in school? ( ) no ( ) yes

If yes, please share. _____________________________________________________

RELIGIOUS/SPIRITUAL INFORMATION

Do you consider yourself to be religious? ( ) no ( ) yes

If yes, what is your faith? ____________________________

If no, do you consider yourself to be spiritual? ( ) no ( ) yes

FAMILY MENTAL HEALTH HISTORY

Has anyone in your family (either immediate family members or relatives) experienced
difficulties with the following? (circle any that apply and list family member, e.g. sibling
parent, uncle, etc.)

Difficulty Yes / No Family member


Depression Yes / No
Bipolar disorder Yes / No
Anxiety disorder Yes / No
Panic attacks Yes / No

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Schizophrenia Yes / No
Alcohol/substance abuse Yes / No
Eating disorders Yes / No
Learning disabilities Yes / No
Trauma history Yes / No
Suicide attempts Yes / No
Chronic illness Yes / No

OTHER INFORMATION

What do you consider to be your strengths? ___________________________________

_______________________________________________________________________

_______________________________________________________________________

What do you like most about yourself? _______________________________________

_______________________________________________________________________

What are effective coping strategies that you have learned? _______________________

_______________________________________________________________________

_______________________________________________________________________

What are your goals for therapy?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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