Client Intake

Your First and Last Name

Parent / Legal Guardian (If under 18)

Address

Your Phone Number

Your Email

Marital Status
Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed

Gender
MaleFemaleOtherPrefer not to disclose

Date of Birth

How did you hear about us?

Have you previously received any type of mental health services?
YesNo

If yes, please provide your previous therapist/practitioner's name

Are you currently taking any prescription medication?
YesNo

If yes, please list:

Have you ever been prescribed psychiatric medication?
YesNo

If yes, please list and provide dates:

How would you rate your current physical health?
PoorUnsatisfactorySatisfactoryGoodVery Good

Please list any specific sleep problems you are currently experiencing:

What types of exercise do you participate in?

How many times a week do you generally exercise?
Less than 11234567

Please list any difficulties you experience with your appetite or eating problems:

Are you currently experiencing overwhelming sadness, grief, or depression?
YesNo

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks, or phobias?
YesNo

If yes, when did you begin experiencing this?

Have you been diagnosed with a personality disorder?
YesNo

If yes, please list:

Are you currently experiencing any chronic pain?
YesNo

If yes, please describe:

Do you drink alcohol more than once a week?
YesNo

How often do you engage in recreational drug use?
NeverInfrequentlyMonthlyWeeklyDaily

Are you currently in a romantic relationship?
YesNo

If yes, for how long?

On a scale of 1-10 (1 being poor, 10 being exceptional), how would you rate your relationship?

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 (e.g., father, grandmother, uncle, etc.).

Alcohol/Substance Abuse

Anxiety

Depression

Domestic Violence

Eating Disorders

Obesity

Obsessive-Compulsive Behaviour

Schizophrenia

Suicide Attempts

Are you currently employed?
YesNo

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current job?

Do you consider yourself to be spiritual or religious?
YesNo

If yes, describe your faith or belief:

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish through therapy?