Intake Form Test

Name*

Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Contact Number*

Email*

Preferred Method of Contact

Ok to leave messages:

Yes
No

Additional Attendees

Name (Person 1)

Date of Birth (Person 1)

Address (Person 1)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name (Person 2)

Date of Birth (Person 2)

Address (Person 2)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

EMPLOYMENT/ACADEMIC INFORMATION:

Employment Status

Currently Employed
On Leave
Not Working

Occupation

Return To Work Date

Education Status

Not attending school
Currently attending

Highest Level Completed

Grade/year

Program

FAMILY AND PERSONAL HISTORY

Are you currently in a relationship?

YES
NO

If yes, tell me a bit more about it:

Do you have children?

YES
NO

Choose a few words to describe your childhood:

Is there a history of mental health concerns from your family of origin?

YES
NO

If yes, tell me a bit more about this:

Are there legal concerns in your life right now?

YES
NO

If yes, tell me a bit more about this:

Are you presently on probation or parole?

YES
NO

Do you feel you have support in your life?

YES
NO

If yes, tell me a bit more about this:

Have you been in therapy before?

YES
NO

If yes, tell me a bit more about this:

What are your positive qualities and skills?

What do you like about yourself?

Please tell us about your plans for the future (career, personal, etc.)

What qualities have helped you to succeed at overcoming difficulties in the past?

THE REASONS FOR YOUR VISIT:

In a few words, what brings you to therapy today?

Who knows about your concerns?

What are some outcomes you would like to see from therapy?

What concerns do you have about attending therapy or working on these problems?

How much are your concerns affect your ability to perform at work or school, get along with others, and perform daily tasks?

Please describe:

Can you remember when they start? What was going on in your life at that time?

How intense is your emotional distress?

Please describe:

In this past year, have you experienced a significant life change or stressor?

YES
NO

If yes, tell me about it:

Have you had thoughts, attempts or suicidal tendencies?

YES
NO

Services

First Session Intake Form

Additional Attendees

EMPLOYMENT/ACADEMIC INFORMATION:

FAMILY AND PERSONAL HISTORY

THE REASONS FOR YOUR VISIT:

If yes, please discuss this during the first session

First Session Intake Form

Additional Attendees

EMPLOYMENT/ACADEMIC INFORMATION:

FAMILY AND PERSONAL HISTORY

THE REASONS FOR YOUR VISIT:

If yes, please discuss this during the first session