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 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 |
| Repetitive behaviors (e.g. frequent handwashing, checking) | Yes / No |
| Repetitive thoughts (e.g. obsessions) | Yes / No |
| Homicidal thoughts | Yes / No |
| Suicidal thoughts | Yes / No If yes, how often and when? |
| Suicidal attempts | Yes / 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.
| Difficulty | Yes / No | Family member |
| 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 | |
| Learning disabilities | 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 are effective coping strategies that you have learned?
_______________________________________________________________________
What are your goals for therapy
______________________________________________________________________
______________________________________________________________________
Janine DeBacker 