Individual Therapy Intake Form

First Name *

Last Name *

Date Filed *

MA#

Age

Date of Birth (1)

Ethnicity:

Sex

Male

Female

Pronouns ( he/she/they):

Sexual Orientation:

Number of children:

Ages of children

Address

Street Address

City

State

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal code

Who do you live with?

Phone *

Work#

Email *

Emergency Contact:

Emergency Contact Telephone #:

Emergency Contact Relationship to the client

For clients under 18 years of age:

Parent's First Name

Parent's Telephone Number

Parent's E-mail Address

Employment Information:

On sick leave, as of this date:

Return to work date:

Position:

Not working because:

Academic Information

School Status

At School Full-time

At School Part time

Not attending school

Educational: (List schools client attended):

Highest school level attended?

How Did You Hear About Us?

How did you hear about this clinic?

Word of Mouth

I'm a former client

Community Partner

Other

Other (Please specify):

The Reason for your visit?

Overall, how much do the problems affect your ability to perform at work, school, get along with others, and perform daily tasks such as chores?

Mildly disruptive 1

2

3

4

Incapacitating 5

How intense is your emotional distress?

Mild 1

2

3

4

5

6

7

8

9

Severe 10

Psychiatric and Mental History

When did these problems start? What was going on in your life at that time?

Please list any psychiatric or "mental" problems you have been diagnosed with:

Please list any medical or physical problems you have been diagnosed with:

Please list any medications you currently take, and what you take them for::

Name of family doctor:

Family doctor telephone

Results of the last doctors checkup?

Name of Psychiatrist:

Psychiatrist telephone number:

Last visit to the Psychiatrist? Month, Day, Year:

Results of the last Psychiatrist checkup?

Mental Health Treatment History

Have you ever been hospitalized for psychological reasons or psychiatric reasons?

Yes

No

If yes, please describe when and where you were hospitalized, and for which reasons.

Please tell us about any other mental health professionals you have consulted with in the past. ( approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment).

Current Habits

Please describe your current habits in each of the areas:

Gambling:

Smoking:

Drinking:

Drug Use:

Caffeine intake:

Exercise:

Fun and relaxation:

Eating:

Sleeping

Normal

Abnormal

Relationships

Please describe your current habits in each of the following areas:

Biological Father

Step Parents

Legal Guardian:

Siblings

Extended family

Your children:

Friends:

Romantic Partner(s)

Colleagues or classmates:

Total number of cloase, supportive relationships?

Stressful Life Events

Please describe any current significant or stressful life events that you have been experiencing:

Economic problems?

No

Yes

Difficulty accessing health care?

No

Yes

Legal Issues or crime?

No

Yes

Cultural Issues?

Family conflict or lack of support?

Social problems?

Educational or occupational difficulties?

Housing problems?

Grief or bereavement?

Other?

Provide 3 specific days and times available for therapy: Example any day before 3pm or Mondays from 9am-3pm, Mondays - Thursdays any time after 5:00pm *

What are you positive qualities and skills? What do you like about yourself? What qualities have helped you to succeed at overcoming difficulties in the past?

Please tell us about your plans for the future (career, personal, etc)

What are your goals for therapy? What would you like to achieve by attending therapy?

How motivated do you feel to work on things in therapy?

What concerns do you have about attending therapy or working on these problems?

Is there anything else that you would like to mention?

Client Signature *

Clear

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