Adult Intake Form

Adult Client General Information

Please provide the following information for our records. Leave blank any questions 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.

Referred By

Client Full Name*

First Last

Card Holders Full Name*

First Last

Primary Phone Number*

May we leave you a message?*

Yes
No

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Client Date of Birth*

Client Age*

Please enter a number from 18 to 100.

Gender*

Male
Female

Emergency Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Adult Client Intake Form

Please provide the following information for our records. Leave blank any questions 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.

Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere?

Yes
No

Have you had previous psychotherapy?

Yes
No

Therapist's Name

If yes, please provide the other therapist's name

First Last

Are you currently taking prescribed psychiatric medication (antidepressants or others)?

Yes
No

If you are taking medications, please list them below:

Health and Social Information

Do you have a primary care physician?

Yes
No

Primary Care Physician

If yes, please list physician's name

First Last

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 below

Are you having any problems with your sleep habits?

Yes
No

Describe your sleep habits:

Check all that apply.

No problems with sleep
Sleeping a little
Sleeping too much
Poor quality sleep
Disturbing dreams
Other

How many times per week do you exercise?

Approximately how long do you exercise each time?

Are you having any difficulty with appetite or eating habits?

Yes
No

Describe your eating habits:

Check all that apply.

Regular eating habits. No problems.
Eating less
eating more
Bingeing
Restricting
Other

Have you experienced significant weight change in the last 2 months?

Yes
No

Do you regularly use alcohol?

Yes
No

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?

Do you smoke cigarettes or use other tobacco products?

Yes
No

Have you had suicidal thoughts recently?

Frequently
Sometimes
Rarely
Never

Have you participated in or have thoughts of self harm?

Frequently
Sometimes
Rarely
Never

If applicable, please explain thoughts of suicide or self harm:

Are you currently in a romantic relationship?

Yes
No

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

On a scale of 1-10 (10 being of 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:

Recent Experiences

Have you experienced any of the following within the last four weeks?

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

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 checking, hand washing)

Yes
No

Homicidal thoughts

Yes
No

Suicidal thoughts

Yes
No

Occupational Information

Are you currently employed?

Yes
No

If yes, what is your current employer / position?

If yes, are you happy with your current position?

Religious / Spiritual Information

Please list any work-related stressors, if any:

do you consider yourself to be religious?

Yes
No

If yes, what is your faith?

If no, do you consider yourself to be spiritual?

Yes
No

Family Mental Health History

Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following?

Depression

Yes
No

Bipolar disorder

Yes
No

Anxiety disorder

Yes
No

Panic attacks

Yes
No

Schizophrenia

Yes
No

Alcohol/substance abuse

Yes
No

Eating disorders

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?

Signature

I have filled out the intake form to the best of my ability.

Client Signature

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Adult Client General Information

Emergency Contact Information

Adult Client Intake Form

Health and Social Information

Recent Experiences

Occupational Information

Religious / Spiritual Information

Family Mental Health History

Other Information

Signature

Address

Client Portal

Address

Client Portal

Phone

Email

Phone

Email