Intake form

Thank you for scheduling an appointment with me. Please print and fill out the form below prior to your appointment. If you are having a virtual appointment, please send me your completed and signed forms beforehand to my email address janinedebacker@msn.com

CLIENT INTAKE FORM

Date __/__/__

Name ____________________________________          Date of birth __/__/__

HEALTH  INFORMATION

Do you currently have a primary physician?  (  ) yes   (  ) no

If yes, who is it? _______________________________________________________

Are you currently seeing more than one medical health specialist?  (  ) yes   (  ) no

      If yes, please list: ______________________________________________________

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:_________________________________________________________________


      ____________________________________________________________________

     Are you having any problems with your sleep habits?  ( ) yes   (  ) no   

     If yes, check where applicable:

(   ) Sleeping too little (   ) Sleeping too much    (   ) Poor quality sleep

            (   ) Disturbing dreams            (   ) other _______________________________

How many times per week do you exercise? ______________Approximately how long each time?

_____________________

Are you having any difficulty with appetite or eating habits? (   ) no   (   ) yes

If yes, check where applicable:  (  ) Eating less     (   ) Eating more   (   ) Bingeing

(   )  Restricting  

Have you experienced significant weight change in the last 2 months?  (   ) no (   ) yes

If yes, how much weight change ____

Do you regularly use alcohol?  (   ) no      (   ) yes

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? 

(   ) daily   (   ) weekly   (   ) monthly  (   ) rarely   (   ) never

Do you smoke cigarettes or use other tobacco products?  (    ) yes     (    ) no

OCCUPATIONAL INFORMATION

Are you currently employed? (   ) no (   ) yes

If yes, who is your currently employer/position? ___________________________

If yes, are you happy with your current position? __________________________

Please list any work-related stressors, if any __________________________________

______________________________________________________________________

______________________________________________________________________

RELIGIOUS/SPIRITUAL INFORMATION

Do you consider yourself to be religious? (   ) no (   ) yes

       If yes, what is your faith? ____________________________

       If no, do you consider yourself to be spiritual?  (   ) no (   ) yes

INTERPERSONAL INFORMATION

Are you currently in a romantic relationship?  (   ) no    (   ) yes

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

On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship? ________

 Do you have close personal friends? ___ Are you close to any family members?____

 Do you have any major stressors in your life right now? _______________________

_____________________________________________________________________

PERSONAL MENTAL HEALTH HISTORY

Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere?   (   ) yes     (   ) no

Have you had previous psychotherapy?

(   ) no

(   ) yes, with (previous therapist’s name)____________________________________

Are you currently taking prescribed psychiatric medication (antidepressants or others)?   (   ) yes   (   ) no

If yes, please list: ______________________________________________________

Prescribed by:  ________________________________________________________

Have you ever experienced any of these symptoms?

Extreme depressed moodYes  /  No
Dramatic mood swingsYes  /  No
Rapid speechYes  /  No
Extreme anxietyYes  /  No
Panic attacksYes  /  No
PhobiasYes  /  No
Sleep disturbancesYes  /  No
HallucinationsYes  /  No
Unexplained losses of timeYes  /  No
Unexplained memory lapsesYes  /  No
Alcohol/substance abuseYes  /  No
Frequent body complaintsYes  /  No
Eating disorderYes  /  No
Repetitive behaviors (e.g. frequent handwashing, checking)Yes  /  No
Repetitive thoughts (e.g. obsessions)Yes  /  No
Homicidal thoughtsYes  /  No
Suicidal thoughtsYes  /  No      If yes, how often and when?
Suicidal attemptsYes / No        If yes, when?

FAMILY MENTAL HEALTH HISTORY

Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following?  (circle any that apply and list family member, e.g. sibling parent, uncle, etc.

DifficultyYes  /  NoFamily member
DepressionYes  /  No 
Bipolar disorderYes  /  No 
Anxiety disorderYes  /  No 
Panic attacksYes  /  No 
SchizophreniaYes  /  No 
Alcohol/substance abuseYes  /  No 
Eating disordersYes  /  No 
Learning disabilitiesYes  /  No 
Trauma historyYes  /  No 
Suicide attemptsYes  /  No 
Chronic illnessYes  /  No 

OTHER INFORMATION

What do you consider to be your strengths?

________________________________________________________________________

What are effective coping strategies that you have learned?

_______________________________________________________________________

What are your goals for therapy

______________________________________________________________________


______________________________________________________________________