Client Intake

Please fill in the information below and send it back through email.

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

Name (*)

Date (*)

Address (*)

Home Phone (*)

May we leave a message?
Yes No 

Cell/Work/Other Phone

May we leave a message?
Yes No 

Email

May we leave a message?
Yes No 

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

DOB:

Age:

Gender:
Male Female Other 

Marital Status:
Never Married Domestic Partnership Married Separated Divorced Widowed 

Referred By (if any):

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
No Yes 

previous therapist/practitioner:

Are you currently taking any prescription medication?
No Yes 

If yes, please list:

Have you ever been prescribed psychiatric medication?
No Yes 

If yes, please list and provide dates:

General and Mental Health Information

1. 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:

2. How would you rate your current sleeping habits? (Please circle one)
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, grief or depression?
No Yes 

If yes, for approximately how long?

6. Are you currently experiencing anxiety, panics attacks or have any phobias?
No Yes 

If yes, when did you begin experiencing this?

7. Are you currently experiencing any chronic pain?
No Yes 

If yes, please describe:

8. Do you drink alcohol more than once a week?
No Yes 

9. How often do you engage in recreational drug use?
Daily Weekly Monthly Infrequently Never 

10. Do you have a history of addictions: Alcohol, drugs, shopping, gambling, food?
No Yes 

11. Are you currently in a romantic relationship?
No Yes 

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?

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

Family Mental Health History In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Please Circle List Family Member Alcohol/Substance Abuse yes / no
No Yes 

If yes,


Anxiety yes / no
No Yes 

If yes,


Depression yes / no
No Yes 

If yes,


Domestic Violence yes / no
No Yes 

If yes,


Eating Disorders yes / no
No Yes 

If yes,

Obesity yes / no
No Yes 

If yes,


Obsessive Compulsive Behavior yes / no
No Yes 

If yes,


Schizophrenia yes / no
No Yes 

If yes,


Suicide Attempts yes / no
No Yes 

If yes,

Additional Information

1. Are you currently employed?
No Yes 

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?
No Yes 

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?

5. What would you like to accomplish in therapy?

6. List 3 of your goals for coaching?

7. On a scale from 1-10, how motivated are you to change and grow?

  I understand that the session (s) I receive are provided for the purpose of healing, releasing, awakening and reclaiming wholeness. I further understand that the session (s) should not be construed as a substitute for diagnosis or treatment. I understand that my practitioner is not qualified to diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the session should be construed as such. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes and understand that there shall be no liability on the practitioner’s part for any reason whatsoever.