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*
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.)No Yes No Yes No Yes No Yes No Yes
Obesity yes / noNo Yes No Yes No Yes No 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?
