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Psychotherapy Intake Questionnaire
Psychotherapy Intake Questionnaire
This form contains sensitive health-related information. All submission of any data provided in this form is encrypted and HIPAA-compliant, ensuring the the privacy of our prospective clients.
36Questions
Psychotherapy Intake Questionnaire
  • 1

    Psychotherapy begins with an intake process, sometimes called a matching process, as the client and the clinician:

    1. identify the client's needs,
    2. determine if these needs can be met by the provider, and
    3. assess if there is a good theraputic fit between the client and the provider.

    Psychologists often specialize in treating particular issues. The information you provide us in this questionnaire will help us to determine if the issues you identify could be treated by us, or if they would be best treated by a different provider.

    Thus, it is important that you take the time to fill out this questionnaire carefully and fully. You should expect it to take at least 10-20 minutes to complete.

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  • 2
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  • 3
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Puerto Rico
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
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  • 4

    Before you proceed, we are not currently licensed to practice in the state that you selected.

    In order to proceed, it will be important to note that we are only able to perform psychological services when you are physically located in one of the following US states:

    Alabama, Arizona, Colorado, Delaware, Georgia, Illinois, Kansas, Kentucky, Maine, Maryland, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Utah, Virginia, and Washington DC.

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  • 5
    This comprehensive intake questionnaire is a lengthy process. We value your time and do not want you to invest too much time if your state's laws do not permit us to practice where you are.
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  • 6
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  • 7
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Puerto Rico
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • United States
    • 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
    • Curacao
    • 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
    • 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
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  • 8

    We are a self-pay practice and the rate for psychotherapy is $238 per 60 minute session, billed to the client at the time of service. We accept most debit and credit cards, as well as flexible spending account (FSA) and health savings account (HSA) cards.

    We do not accept insurance as it is our preference to invest our time and attention to clients, as opposed to negotiating with insurance companies. This provides far greater flexibility in care and allows clinicians to meet clients’ needs first rather than the rigid, impersonal, and often arbitrary expectations set by insurance companies.

    Depending on your personal preferences and insurance plan, you may still be able to use your insurance provider to pursue full or partial reimbursement for our services as an "out-of-network provider".

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  • 9
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  • 10
    This comprehensive intake questionnaire is a lengthy process. We value your time and do not want you to invest too much time if our requirements do not align with your expectations.
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  • 11
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  • 12
    Is there something specific, such as a particular event? How long has this/these been in your life? Be as detailed as you can.
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  • 13
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  • 14
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  • 15
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  • 16
    -
    Pick a Date
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  • 17
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  • 18
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  • 19
    Do you live alone, with family, others, etc.? Do you have social support such as friends, family, close friends, etc.? If you are in a romantic relationship, please describe the nature of it and how long you have been in the relationship.
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  • 20
    Friends, family, close friends, coworkers, etc.
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  • 21
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  • 22
    Include any partners, parents, children, etc. Please describe.
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  • 23
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  • 24
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  • 25
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  • 26
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  • 27
    Please include name and phone number
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  • 28
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  • 29
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  • 30
    Please include name and phone number
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  • 31
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  • 32
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  • 33
    Please select all that may apply
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  • 34
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  • 35
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  • 36
    What did you focus on? How was the experience? Are there things you liked/disliked?
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  • 37
    This could include traumatic experiences, moving frequently, a family divorce, a major illness, etc.
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  • 38
    This could include traumatic experiences, moving frequently, a family divorce, a major illness, etc.
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  • 39
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  • 40
    Please include the nature of these thoughts/urges, whether you ever acted on them, how recently these have occurred, etc.
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  • 41
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  • 42
    Please describe the frequency, intensity, content, and whether it involves any particular method
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  • 43
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  • 47
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  • 48
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  • 49
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  • 50
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  • 51
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  • 53
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  • 54
    This could also include suspected mental health challenges that are undiagnosed.
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  • 57
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  • 64
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  • 66
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  • 68
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  • 70
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