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Intake Questionnaire
Therapist Name:
Name
Address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
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
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Email Address
example@example.com
Do you agree to allow us to communicate with you via unencrypted email and/or text? (i.e. email that is not password protected such as gmail, yahoo, outlook, etc.)
Yes
No
Preferred phone number
Please enter a valid phone number.
Is it okay to leave a voice message?
Yes
No
How were you referred here?
Emergency Contact Name & Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
If the internet which site?
Age
Date of Birth
-
Month
-
Day
Year
Date
City/State of birth
Where did you grow up
Are your parents alive?
Yes
No
Are you in contact with them?
Yes
No
How many siblings do you have?
Please list starting with the oldest and include yourself:
Which siblings are you in contact with?
Are you?
Single
Married
Divorced
How many times have you been married/long term relationships?
Please list names of previous spouses/partners
How many times have you been divorced/separated?
From who?
Who is in your life presently?
What family members are you close to?
What family members are you distant from?
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Do you have children?
Yes
No
If so how many?
Please list names of children and ages starting with the youngest
What is your occupation?
Full or part-time?
Full
Part-time
What is your religion, if any?
What are your hobbies?
Please list those in your support system
Do you have any history of abuse?
Yes
No
What type of abuse have you experienced?
Please Select
Physical
Verbal
Sexual
Neglect
Domestic
Emotional/Psychological
Are you presently in therapy?
Yes
No
Please list present therapist:
Past therapy/psychiatric Experiences?
Yes
No
Duration of therapy in past?
Please list names of all previous treatment practitioners/psychiatrists
Are you presently under the care of a psychiatrist?
Yes
No
Are you presently on psychiatric medications?
Are you presently under care of a medical doctor?
Yes
No
Are you presently on any medical medication(s)? Please list
Have you had any psychiatric hospitalizations?
Yes
No
Please list all hospitalizations and duration:
Please list any medical hospitalizations
Have you ever been arrested?
Yes
No
Please list the reason
Do you have legal problems?
Yes
No
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Please list any legal problems
Please describe the reason you are seeking therapy
What goals in therapy would you like to achieve?
How long do you see yourself needing to achieve these goals?
Please Select
1-3 months
3-6 months
6-8 months
Why are these goals important?
Please list any other comments in order to help identify problem areas
Who else would you like to include in your treatment?
Thank you for taking the time to completely fill out this form.
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Symptom Assessment
Please answer the following:
I AM EXPERIENCING…
Never
Seldom
Often
Always
For how long?
Frequent worry or tension
Fear of many things
Discomfort in social situations
Feelings of guilt
Phobias: unusual fears about specific things
Panic Attacks: Sweating, trembling, shortness of breath, heart palpitations
“Flashbacks” as if reliving the traumatic event
Avoiding people/places associated with trauma
Nightmares about traumatic experience
I USE THE FOLLOWING….
Never
Seldom
Often
Always
For how long?
Alcohol
Nicotine (Cigarettes)
Marijuana
Cocaine
Opiates
Sedatives
Hallucinogens
Stimulants
Methamphetamines
I AM FEELING…
Never
Seldom
Often
Always
For how long?
Decreased interest in pleasurable activities
Social Isolation, Loneliness
Suicidal Thoughts
Bereavement or Feelings of Loss
Changes in sleep (too much or not enough)
Normal, daily tasks require more effort
Sad, hopeless about future
Excessive feelings of guilt
Low self-esteem
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MY EATING INVOLVES…
Never
Seldom
Often
Always
For how long?
Restriction of food consumption
Bingeing and Purging
Binge Eating
A lot of weight loss or gain
I NOTICE...
Never
Seldom
Often
Always
For how long?
I am Angry, Irritable, hostile
I feel euphoric, energized and highly optimistic
I have racing thoughts
I need less sleep than usual
I am more talkative
My moods fluctuate: go up and down
I HAVE…
Never
Seldom
Often
Always
For how long?
Memory problems or trouble concentrating
Trouble explaining myself to others
Problems understanding what others tell me
Intrusive or strange thoughts
Obsessive Thoughts
Been hearing voices when alone
Problems with my speech
I HAVE…
Never
Seldom
Often
Always
For how long?
Risk Taking behaviors
Compulsive or repetitive behaviors
Been acting without concern for consequence
Been physically harming myself
Been violent toward other(s)
I HAVE…
Never
Seldom
Often
Always
For how long?
Concern about my sexual function
Discomfort engaging in sexual activity
Questions about my sexual orientation
EMPLOYMENT & SELF-CARE
Never
Seldom
Often
Always
For how long?
I have problems getting/keeping a job
I have problems paying for basic expenses
I am afraid of becoming homeless
I have problems accessing healthcare
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