Forms

Client Intake Questionnaire

Please fill in the information below and Send before your first session. You can send this form by clicking the send button at the end of the completed form.

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

Please read the Statement of Confidentiality and check below.

I have read and understand the Statement of Confidentiality

Please Check

First Name

Last Name

Date

ת"ז

Parent/Guardian

Address

Home Phone Number

May we leave a message?

Yes No

Cell Phone Number

May we leave a message?

Yes No

Work/Other Phone Number

May we leave a message?

Yes No

May we leave a message?

Yes No

* Please note: Email correspondence is not considered to be a confidential medium of communication

DOB:

Age:

Gender:

Marital Status:

Never Married Domestic Partnership Married Separated Divorced Widowed

Do You Have Children?

Yes No

Do They Live With You?

Yes No

If You Have Children, Please List Their Gender, Name and Age:

Emergency Contact Person:

Relationship to Client:

Contact's Phone Number:

Contact's Email:

Referred By (If Any):

Have you previously received any type of mental health services (psychotherapy, psychiatric services etc.)?

yes no

Previous therapist/practitioner:

Are you currently taking any prescription medication?

yes no

If yes, please list

Have you ever been prescribed psychriatric medication?

yes no

If yes, please list and provide dates

1. How would you rate you current physical health?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific health problems you are currently experiencing?

2. How would you rate you current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing?

3. How many times per week do you generally exercise?

What types of exercise do you participate in?

4. Please list any difficulties you experience with your appetite or eating problems:

5. Are you currently experiencing overwhelming sadness/ greef, or depression?

Yes No

If yes, for approximately how long?

6. Are you currently experiencing anxiety, panic attacks or have any phobias?

Yes No

If yes, when did you begin experiencing this?

7. Are you currently experiencing any chronic pain?

Yes No

If yes, please describe:

8. Do you drink alcohol more than once a week?

Yes No

When do you drink alcohol?

9. How often do you engage in recreational drug use?

Daily Weekly Monthly infrequently Never

10. Are you currently in a romantic relationship?

Yes No

If yes, for how long?

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?

11. What significant life changes or stressful events have you experienced recently?

In the section below, identify (by checking yes or no) if there is a family history of any of the following. If yes, please indicate the family member's relationship in the space provided (e.g. father, grandmother, uncle, etc.)

Alcohol/Substance Abuse

Yes No

Anxiety

Yes No

Depression

Yes No

Domestic Violence

Yes No

Eating Disorders

Yes No

Obesity

Yes No

Obsessive Compulsive Behavior

Yes No

Schizophrenia

Yes No

Suicide Attempts

Yes No

1. 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?

2. Do you consider yourself to be spiritual or religious?

Yes No

If yes, describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy?

I have read and understand the Statement of Confidentiality

Please Check

First Name

Last Name

Date

ת"ז

Parent/Guardian

Address

Home Phone Number

May we leave a message?

Yes No

Cell Phone Number

May we leave a message?

Yes No

Work/Other Phone Number

May we leave a message?

Yes No

May we leave a message?

Yes No

* Please note: Email correspondence is not considered to be a confidential medium of communication

DOB:

Age:

Gender:

Marital Status:

Never Married Domestic Partnership Married Separated Divorced Widowed

Do You Have Children?

Yes No

Do They Live With You?

Yes No

If You Have Children, Please List Their Gender, Name and Age:

Emergency Contact Person:

Relationship to Client:

Contact's Phone Number:

Contact's Email:

Referred By (If Any):

Have you previously received any type of mental health services (psychotherapy, psychiatric services etc.)?

yes no

Previous therapist/practitioner:

Are you currently taking any prescription medication?

yes no

If yes, please list

Have you ever been prescribed psychriatric medication?

yes no

If yes, please list and provide dates

1. How would you rate you current physical health?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific health problems you are currently experiencing?

2. How would you rate you current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing?

3. How many times per week do you generally exercise?

What types of exercise do you participate in?

4. Please list any difficulties you experience with your appetite or eating problems:

5. Are you currently experiencing overwhelming sadness/ greef, or depression?

Yes No

If yes, for approximately how long?

6. Are you currently experiencing anxiety, panic attacks or have any phobias?

Yes No

If yes, when did you begin experiencing this?

7. Are you currently experiencing any chronic pain?

Yes No

If yes, please describe:

8. Do you drink alcohol more than once a week?

Yes No

When do you drink alcohol?

9. How often do you engge in recreational drug use?

Daily Weekly Monthly infrequently Never

10. Are you currently in a romantic reationship?

Yes No

If yes, for how long?

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?

11. What significant life changes or stressful events have you experienced recently?

In the section below, identify (by checking yes or no) if there is a famiy history of any of the followig. If yes, please indicate the family memgeer's relatioship in the space provided (e.g. fahter, grnandmother, uncle, etc.)

Alcohol/Substance Avuse

Yes No

Anxiety

Yes No

Depression

Yes No

Domestic Violence

Yes No

Eating Disorders

Yes No

Obesity

Yes No

Obsessive Compulsive Behavior

Yes No

Schizophrenia

Yes No

Suicide Attempts

Yes No

1. 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?

2. Do you consider yourself to be spiritual or religious?

Yes No

If yes, describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy?