Therapy Intake Form Name * First Name Last Name Gender Date of Birth * MM DD YYYY Contact Information Phone Number * (###) ### #### Email * Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Communication Method * Phone Text Email Emergency Contact Name * First Name Last Name Phone * (###) ### #### Relationship In case of an emergency, do I have permission to contact this person? Yes No Medical History Have you previously received therapy? Yes No Have you previously been prescribed psychiatric medication? Yes No What psychiatric medications are you currently taking? * List n/a if not currently taking meds. Who prescribes your psychiatric medications? * List n/a if not currently taking meds. Do you have any pre-existing medical conditions? Is there anything else regarding your medical history that I should be aware of? Family History What is your current relationship status? Single Dating Common Law Married Separated Divorced Widowed Other Is there anything regarding your relationship you would like me to be aware of? Do you have any children? Yes No If yes, briefly describe your relationship with your children. Briefly describe your relationships with your parents. Do you have any siblings? Yes No Briefly describe your relationship with your siblings. Is there anything else regarding your family history that I should be aware of? Family Mental Health History Depression Anxiety Traumatic History Substance Abuse Hallucinations Other Which family member(s) dealt with the above issues? Personal History What is your highest level of education? Are you currently employed? Yes No If yes, what is your current occupation? Check all that apply Tobacco THC/Cannabis Stimulants (Meth, Cocaine, etc.) Hallucinogens (Mushrooms, LSD, etc.) Other How often do you have time for fun and recreational activities? Regularly Occasionally Never Do you drink alcohol? Regularly Occasionally No Do you drink caffeine? Regularly Occasionally No Do you gamble? Regularly Occasionally No How often do you get a full night of sleep? Regularly Occasionally Never Do you exercise? Regularly Occasionally No Do you have a healthy and balanced diet? Regularly Occasionally No Current symptoms * Please check the symptoms that you currently experience or have experienced in the last 30 days: Anger Anxiety Difficulty being in crowds Difficulty sleeping Difficulty concentrating Compulsive behaviors Depression Disturbing/bothersome thoughts Eating too much Not eating enough Fearful Feeling worthless Lack of appetite Grief Sadness Guilt Hearing things Hopelessness Identity concerns Impulsivity Lack of confidence Lack of interest in activities/work/school Nervous Obsessive thinking Feeling overwhelmed Panic attacks Feeling that others are out to get me Poor memory Prefer being alone Nightmares Relationship issues Restlessness Seeing things Self-harm Sleep changes Sleeping too little Sleeping too much Stress Substance use Feeling suspicious of others Talking too fast Talking too slow Feeling tired/fatigue Briefly described any traumatic events you’ve experienced; Including but not limited to: physical/sexual assault, abuse, bullying, etc. You may be as detailed as you are comfortable with. Is there anything else regarding your personal history that I should be aware of? What hobbies do you enjoy in your spare time? How do you practice self-care? Do you identify with a religion or spirituality? If so, please identify: Reasons for Visit Describe the reasons you are seeking therapy. Describe any goals or outcomes you hope to achieve from therapy. Describe any significant life changes or stressful events that you have recently experienced. Is there anything else you'd like to tell me about? Thank you! Emergency AssistanceIf this is an emergency, call: Crisis Line: (800) 692-4039911
