Individual Intake FormPart 1 Personal Information Today's Date * MM DD YYYY Name * First Name Last Name What you like to be called Phone Number Please list the number you'd like me to use - Home, Mobile, etc. (###) ### #### Communication Preference Please let me know if it is okay to text you if I cannot reach you on the phone. Yes No Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Age Gender Female Male Non-Binary Prefer not to say Other Emergency Contact Information Emergency Contact First Name Last Name Emergency Contact's Phone (###) ### #### Emergency Contact Relationship Reason for Seeking Treatment Please briefly describe the problems you are experiencing. What has happened to cause you to seek help now? What do you hope to be able to do or achieve as a result of treatment? How do you handle stressors and/or cope with the problems you have described? Do you currently have thoughts of harming yourself? Yes No Have you in the past? Yes No If Yes, how long ago? Do you currently have thoughts of wishing you were dead? Yes No Do you currently have urges to hurt, harm, or kill someone else? Yes No If Yes, whom? Have you ever seriously considered suicide or felt like harming someone else? Yes No If Yes, please explain. Name of Current Psychiatrist, if applicable. First Name Last Name Current Psychiatrist's Phone, if applicable. (###) ### #### Have you ever had previous therapy/counseling of any kind? Yes No If yes, when, with whom, and for how long? Have you ever been hospitalized for emotional problems? Yes No Or for substance abuse problems? Yes No If yes to either of the above, please note when, where, and for how long were you hospitalized? Areas of Focus Please check all of the items below that describe your situation. Abuse/trauma -physical, sexual, emotional, neglect Aggression, violence Alcohol use Anger, hostility, arguing, irritability Anxiety, nervousness Attention, concentration, distractibility Career concerns, goals, and choices Childhood issues Codependence Confusion Compulsions and/or obsessions (thoughts or actions that repeat themselves) Decision-making, indecision, mixed feelings, putting off decision Delusions (false ideas) Dependence Depression, low mood, sadness, crying Divorce, separation, marital conflict, infidelity/affairs Drug use -prescription medications, over-the-counter medications, street drugs Eating problems -overeating, under-eating, appetite, vomiting Emptiness Failure Fatigue, tiredness, low energy Fears, phobias Financial or money troubles, debt, impulsive spending, low income Gambling Grieving, mourning, deaths, losses, divorce Guilt Headaches, other kinds of pains Health, illness, medical concerns, physical problems Inferiority feelings Impulsiveness, loss of control, outbursts Irresponsibility Judgment problems, risk taking Legal matters, charges, suits Loneliness Memory problems Mood swing Oversensitivity to rejection Panic or anxiety attacks Perfectionism Pessimism Procrastination,. lack of motivation Relationships problems (with friends, with relatives, or at work) School problems Self-centeredness Self-esteem Self-neglect, poor self-care Sexual issues, dysfimctions, conflicts, identity issues Sleep problems (too much, too little, insomnia, nightmares) Spiritual, religious, moral, ethical issues Stress and tension Suspiciousness Suicidal thoughts Temper problems, self-control, low frustration tolerance Thought disorganization and confusion Threats, violence Weight and diet issues Withdrawal, isolation Work problems, employment issues Substance Abuse History Have you ever experienced a problem with alcohol, drugs, or prescription medications? Yes No If Yes, please explain. Have you ever been treated for problems with alcohol, drugs, or abuse or prescription medications? Yes No If Yes, please explain. Has anyone (family, doctors, friends, coworkers, bosses, etc.) ever expressed concern that you might have a problem with alcohol or drugs? Yes No If yes, please explain. Have you had any problems related to use of alcohol/drugs in the past year? Yes No If Yes, please explain. Has drinking or drug use ever caused you problems in the following areas? (Check if yes). Family School Employment Legal Emotional Social Financial Behavior Physical health Family Background Children/Dependents If you don't have children skip to the next question. Names, Ages, Grades, Schools, and if they live with you. Other than any children already indicated above, who lives in your household? Family Members Check those still living. Father Mother Step Father Step Mother Spouse/Partner Sister(s) Brother(s) Please describe the quality of relationships with your other family members: Whom were you raised by? Were you adopted? Yes No If Yes, at what age were you adopted? What family member(s) were you closest to as a child? What family member(s) are you closest to now? Check the statement(s) below that describe the type of family you grew up in Overly close family No "breathing room" Everyone was in everyone else's business No privacy Boundaries not respected Comfortably close family Loving Shared many positive experiences Supportive Distant, everyone did their own thing Not much time spent together Not a lot of support Angry, lots of fighting/hostility Verbal abuse and conflicts Violence Frightening Scared to make mistakes Have any biological relatives ever had any emotional problems or substance abuse? Yes No If Yes, please explain. Has anyone in your family ever attempted or committed suicide? Yes No If Yes, please explain. You have completed Part 1. Please follow the link below to finish Part 2. This is the end of Part 1 only. Please click the Submit button to complete Part 2.
