New Client - Adult

Mental Health and Medical History

New Client Adult - Intake Form

Previous Mental Health Treatment or Evaluation

	Date(s)	Therapist/Facility	Reason for Seeking Treatment/Evaluation
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Please review and answer the questions below.

	Yes/No	If yes, please provide additional details.
Have you ever been hospitalized for mental health issues?
Have you ever had thoughts about hurting yourself and/or another person?
Have you ever acted upon hurting yourself and/or another person?
Any current legal involvement?

Alcohol or Substance Abuse

	Yes/No	If yes, provide additional details.
Has using drugs or alcohol ever caused problems for you?
Have you ever been treated for drug or alcohol abuse?

Medical History - Please list all medical concerns below.

If applicable, please provide Psychiatrist or prescribing physician's information

	Name	Address	Phone Number	Diagnosis
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Current Medications

	Medication	Dosage	Reason for Prescription	How long on Medication?	Prescribing Physician
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Home and Family Information

New Client Adult - Intake Form

Family Members

	Name	Age	Gender	Relationship	Living at home? (Y/N)
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Is there any unrelated person residing at your home? If so, who are they?
Is there a family history of mental health issues in your family? (i.e. ADHD, learning problems, depression, anxiety, bipolar disorder, schizophrenia, substance abuse, etc.)? (If yes, please describe)
Is there a history of drug and/or alcohol abuse in the family?
Is there a history of suicide in the family?
What was your birth order: blanks out of blank.

Education and Employment History

New Client Adult - Intake Form
What is your highest grade completed?
Do you have any history of learning disabilities?
What is your current employment?

Confirmation and Signature

New Client Adult - Intake Form
Is there anything else that might be important for me to know?
My signature below indicates that I have voluntarily and accurately completed this form. A photocopy of this agreement will be considered as valid as an original.
Client Name (completing this form)*

First NameLast Name
Signature of Client*

Clear
Today's Date*

MonthDayYear
Please verify that you are human*
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