Skip to content
“Unveiling the Secrets of the Human Mind.”
Home
About
Education
Services
Client information form
Pre Intake Form
Menu
Home
About
Education
Services
Client information form
Pre Intake Form
Join Telehealth session
Home
About
Education
Services
Client information form
Pre Intake Form
Menu
Home
About
Education
Services
Client information form
Pre Intake Form
Join Telehealth session
Home
About
Education
Services
Client information form
Pre Intake Form
Menu
Home
About
Education
Services
Client information form
Pre Intake Form
Name
Address
City
State
Zip
Phone Nmmber
Email Address
What is the best way to contact you?
May I leave a detailed message at this number or email?
Select
Yes
No
Gender
Select
Male
Female
Transgendered
Other(specify)
Date Of Birth
Age
Relationship Status
Select
Single
Married/Partnered
Divorced
Separated
Widowed
Recent Breakup
Other(Specify)
Ethnic Origin
Select
White/Euro-American
African American
Asian/Pacific Islander American
Hispanic/Latino(a)/Mexican American
Native American/American Indian
Mixed Ethnicity
Other(Specify)
Occupation
Emergency contact
*
*
Does emergency contact person know you are in counseling?
Referred by
Prior experience with therapy
Yes
No
If yes, with whom? concerns discussed? and for how long (please include dates)?
Have you ever been hospitalized for a psychiatric condition?
Yes
No
If yes, for what condition? Where? and for how long (please include dates)?
Are you currently taking any medications? Please list all medications you are taking and when you started?
Please check all that apply to you
Select
Feeling depressed/unhappy
Anxious/Nervous
Headaches or physical problems
Feel Tired/Dizzy/Weak
Have fears which seem unrealistic
Past physical or sexual abuse
Anxious in social situations
Bothered by sleep difficulties
Upset about a physical problem
Difficulty expressing emotion
I often get extremely angry
I have acted violently
Concerned about relationship loss
Unhappy with social life
Concerned about my marriage/Relationship
Unhappy with dating life
Cannot control my thoughts/actions
Difficulty trusting others
I do not handle stress well
Don’t get along with family
Trouble adjusting to new situation
Thinking of killing myself
Sexual concerns to discuss
Cutting or self-harm
Sometimes I do not know where I am
Sexual orientation concerns
I’ve had an unwanted sexual experience
Work-related problems
Sometimes I don’t know where I am
Having money problems
I sometimes hear voices in my head
Upset about a recent death
Worry about drinking/drug habits
Unsure about my future
I feel people are out to get me
Wish I could be different
Stealing/trouble with the law
Legal problems
Nightmares or flashbacks
Poor job performance
Trouble concentrating
Loss of motivation
Learning Disability
ADD or ADHD
Body image concerns
Dieting/restricting food
Binge eating
Unhappy with weight
Self-induced vomiting
Abuse of laxatives
Compulsive exercise
Use of diet pills or diuretics
Other(please specify)
I have felt like or tried harming
Major medical problems or disabilities
Have you had any serious illness or injuries?
Select
Yes
No
If yes, what?
The following have resulted from my drinking and/or use of drugs:
Select
Traffic ticket/violation
Fight with a friend/loved one
Ruined a relationship
Academic problems
Black outs
Work disciplinary problems
Criticized about my drinking
Felt the need to cut down on use
Felt guilty about my use
Loss of self-respect
Engaged in sexual behavior I later regretted
Please list all medications you are taking:
What are you seeking treatment for at this time?
Family Information
At least one person in my family has a history of:
Counseling
Psychiatric Hospitalization
Depression
Eating Disorder
Anxiety
Alcoholism/Substance Abuse
Suicidal Behavior
Poor Communication
Abuse
Other(specify)
Send