CONFIDENTIAL CLIENT INTAKE INFORMATION QUESTIONNAIRE

Date:

SSN:

Referred By:

Date of Birth:       Age:

Gender:

Male Female

Religion:

What Ethnic group do you identify with:

What is your --

Address:

City:

State:       ZIP:


Email:

Telephone:

Home:

Work:

Cell:

Payment Information:

I accept cash, checks, and credit card payments. Payments are to be made prior to the start of each session. For credit card payments, please fill out the following information:

Credit Card No:

CVV: Exp:

Name:

(as it appears on card):


Occupation:

Employer Name & Address:

Name:

Address:

City:

State:       ZIP:

Highest level of education completed:

Are you in school now?

YES NO

If YES, what school and what is your area of study?

Are you married or in a committed emotional relationship now (if applicable)? YES NO

If Yes, how long?

Partner's Name:

Partner's

Occupation:


Number and duration of previous marriages or partnerships.

You:

Your Partner:

Please list the name, age and gender of each person living in the home:

What prompted you to seek counseling at this time?

How long have you been concerned about this issue or problem? (When/How did it start?)

Who is involved/affected by the problem? Describe their involvment.

What have you already done to try to solve the problem? What has helped (even if only a little) and what has failed to help?

If the problem were solved, how would your life be different?

What are your goals for therapy?

HEALTH HISTORY INFORMATION

What is the name, address and phone number of your physician?

Name:

Address:

City:

State:       ZIP:

Telephone:


Have you been under a physician's care for any reason in the last 5 years? If yes, please explain.

Have you ever been hospitalized? Yes No

If yes, please list the date of each hospital stay and the reason for the stay.

List any medication you are taking now and the purpose for taking them.

Have you (or your child/teen/family) been involved in therapy or any type of counseling programs?

Yes No

If yes:

When?

Where?

Reason for and length of counseling


How was therapy helpful or not helpful?

Rate the following using a scale of 1 - 3

1 = Never     2 = Occasionally     3 = Often

M1


chronic sadness

crying episodes

hopelessness

difficulty concentrating

weight loss

weight gain

loss of appetite

overeating

nausea/vomiting

difficulty making decisions

recurring thoughts of death or dying

mood swings

low frustation tolerance

irritability

sleep problems

memory problems

thoughts of suicide

withdrawing from others

difficulty functioning at work

difficulty functioning socially

low energy/fatigue

reduced interest/pleasure

feelings of worthlessness/guilt

staying up for days without sleep

A1


agitation

restlessness

excessive worry

fearfulness

trembling/shaking

fear of loss of control

fear of dying

feeling detached from others/life

intrusive thoughts of bad memories

nightmares

panic attacks

fear of leaving home

avoidance of public places

avoidance of social situations

pounding heart/palpitations/shortness of breath

chest pain

flashbacks/reliving bad experiences

easily startled/upset

difficulty waiting your turn

obsessive or compulsive

SA1


excessive use of alocohol/drugs

use substances to cope with difficult feelings/life problems

history of substance abuse in family

memory loss following substance abuse

health problems/accidents due to substance abuse

fail at efforts to reduce use of alcohol/drugs

substance use causing problems with friends/family/work

legal problems related to substance use

cigarette use is troublesome/causing health problems

unconsciousness due to substance use

ED1


excessive eating

underweight

use of laxatives

eating problems interfering with health

obesity

self-induced vomiting

obsessing about food, diet, exercise

TD1


hearing voices others do not hear

fearful others are talking about you

seeing things others do not see

fearful someone is plotting against you

ATTFOC1


difficulty completing tasks/distractible

difficulty focusing

racing thoughts

not well organized

taking on more tasks than can be completed

frequent forgetfulness

BEH1


tendency to be impulsive

excessive gambling

excessive spending

aggressive/abusive toward others

high risk sexual behavior

confused/worried about sexual behavior

difficulty at work/do not stay on the same job

difficulty adjusting to new situations

problems in school growing up

marital conflict

other family conflicts

BEH11


inability to trust others

lack of desire for intimacy

difficulty expressing emotions

problems with legal authorities

volatile, unstable relationships, personal and/or professional

excessive emotionality that results in needed attention from others

grandiose sense of self, with little empathy for others

fear of rejection from others, resulting in avoiding people, events or situations

difficulty in making decisions for self without the advice of others

preoccupation with orderliness, perfectionism, and control

Is there anything else you think would be helpful for me to know about you or your situation?

No information about you is released to anyone without your written consent, except as required by law or court order. I am required by law to report suspected child abuse, elder abuse, and clear, concrete evidence of planned acts of violence towards oneself or others.



 

Client Signature

Date  


 

Parent/Guardian Signature (if needed)

Date