Client Intake Form
Tell me about you
Please provide the following information and answer the questions below.
Please note that the information provided on this form is protected as confidential information.
Client Name:_________________________________________________
Parent/Legal Guardian (if under 18):________________________________
Client Birth Date_____________________ Age _______________
Gender: Male ________ Female______
Address: ___________________________City _______________ Zip Code ______
Home Phone: (______ )_____________-__________________
May we leave a message? □ Yes □ No May we leave a message? □ Yes □ No May we leave a message? □ Y □ No
Cell/Work/Other Phone: ( _____) ____________-_____________
May we leave a message? □ Yes □ No May we leave a message? □ Yes □ No May we leave a message? □ Y □ No
Email:________________________________________
*Please note: Email correspondence is not considered to be a confidential medium of communication.
Marital Status:
□ Never Married □ Domestic Partnership □ Married □ Separated □ Divorced □ Widowed
Referred By (if any): ______________________________________
History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
□ No □ Yes, previous therapist/practitioner: _________________________________________
Are you currently taking any prescription medication? □ Yes □ No
If yes, please list: __________________________________________________________________
___________________________________________________________________
Have you ever been prescribed psychiatric medication? □ Yes □ No
If yes, please list and provide dates: ______________________________________________________________________________________________________________________________________
General and Mental Health Information
1. How would you rate your current physical health? (Please circle one)
Poor Unsatisfactory Satisfactory Good Very good
Please list any specific health problems you are currently experiencing
___________________________________________________________________
2. How would you rate your current sleeping habits? (Please circle one)
Poor Unsatisfactory Satisfactory Good Very good
Please list any specific sleep problems you are currently experiencing: ___________________________________________________________________
___________________________________________________________________
3. How many times per week do you generally exercise___________________________
What types of exercise do you participate in? ___________________________________
4. Please list any difficulties you experience with your appetite or eating problems:
___________________________________________________________________
5. Are you currently experiencing overwhelming sadness, grief or depression? □ No □ Yes
If yes, for approximately how long? __________________________________________
6. Are you currently experiencing anxiety, panics attacks or have any phobias? □ No □ Yes
If yes, when did you begin experiencing this? _________________________________
7. Are you currently experiencing any chronic pain? □ No □ Yes
If yes, please describe: ___________________________________________________________
8. Do you drink alcohol more than once a week? □ Yes □ No
9. How often do you engage in recreational drug use? _____________________________
□ Daily □ Weekly □ Monthly □ Infrequently
10. Are you currently in a romantic relationship? □ No
If yes, for how long? _____________________________________________________________
On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship? ___________________________________________________________________
11. What significant life changes or stressful events have you experienced recently?
___________________________________________________________________
Family Mental Health History
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.) □ No □ Never □ Yes
Alcohol/Substance Abuse: □ No □ Never □ Yes ______________
Anxiety: □ No □ Never □ Yes ______________
Depression: □ No □ Never □ Yes ____________
Domestic Violence: □ No □ Never □ Yes ___________
Eating Disorders: □ No □ Never □ Yes _____________
Obesity : □ No □ Never □ Yes ____________
Obsessive Compulsive Behavior: □ No □ Never □ Yes _______________
Schizophrenia: □ No □ Never □ Yes ______________
Suicide Attempts: □ No □ Never □ Yes ________________
Employment
Are you currently employed? Please Circle yes/no
If yes, what is your current employment situation? ___________________________________________________________________
Do you enjoy your work? Is there anything stressful about your current work? ___________________________________________________________________
___________________________________________________________________
2. Do you consider yourself to be spiritual or religious? □ No □ Yes
If yes, describe your faith or belief: ___________________________________________________________________
3. What do you consider to be some of your strengths? ___________________________________________________________________
___________________________________________________________________
4. What do you consider to be some of your weaknesses? ___________________________________________________________________
___________________________________________________________________
5. What would you like to accomplish out of your time in therapy? ___________________________________________________________________
If you are interested in participating in services with PCC, please complete complete the contact form and / or contact our office at (424) 488-7879 to schedule an appointment.
We look forward to hearing from you.