Client Intake Questionnaire

Legal Name *

First

Last

Preferred Name:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Birthdate:

Age

Consider myself (Check all and any that apply)

Sexual Orientation, consider myself:

I am currently: (Check any that currently apply to you, even if more than one. Enter the time frame and circle "months" or "years")

Single For months and years?

Dating For months and years?

Cohabiting For months and years?

Married For months and years?

Sperated For months and years?

Divorced For months and years?

Never Married For months and years?

Widowed For months and years?

Have you been married previously (Not counting at present)?

Yes
No

If Yes, how many times?

Do you have biological children of your own?

Yes
No

If yes, how many children do you have and bio-children live with you?

Education *

Graduate Degree:

Current Occupation: *

Years at Current Job

Hrs per week:

Do you enjoy your work? *

Career Goals:

If you are in a relationship with a spouse, boyfriend, girlfriend or partner, please rate how much you have experience each of this additional six symptomes in your relationship over the past two weeks. If you are single, select all 0's in the next six statements and enter the total of 1 through 25 in the box below.

If you are in a relationship with a spouse, boyfriend, girlfriend, or partner, please rate how much you have experienced each of these additional six symptoms in your relationship over the past two weeks. If you are single, select all 0s in the next six statements and enter the total of 1 through 25 in the box below.

1. Not talking to each other *

2. Having bad arguments *

3. Lack of trust between us *

4. Feeling lonely in the relationship *

5. Lack of affection and caring between us *

6. Feeling unhappy about our relationship *

Symptom Total *

(sum of all 25 symptoms)

Medical: Do you have any medical problems?

Yes
No

If yes, please list them

Do you take any prescription Medications? if yes, please list them

Yes
No

Medication

Dose

Purpose

Since

Do you Exercise?

Yes
No

If yes, what do you do?

Do you drink alcohol?

Yes
No

If yes, estimate how many times you typically drink in a month?

Do you smoke tabacco?

Yes
No

If yes, please estimate quantity per day:

Do you drink coffee/ tea?

Yes
No

If yes, please estimate quantity per day:

Do you use any illicit drugs?

Yes
No

If yes, please specify:

If you drink alcohol or use illicit drugs, please answer the following questions:

Have you ever though you should cut down on your drinking/ drug use? *

Have people annoyed you by criticizing your drinking/ drug use? *

Have you ever felt bad or Guilty about your drinking/ drug use? *

Have you ever had a drink / used drugs in the morning (Eye Opener) to steady your nerves or to get rid of a hangover? *

Are you concerned about the alcohol and/ or drug use of anyone close to you?

Yes
No

If yes, who?

In any of your current relationships, have you been: Physically assualted (hit, slapped, kicked, pushed, held down)?

Yes
No

If Yes, By?

The subject of demeaning, degrading comments or put downs?

Yes
No

If Yes, By?

Sexually abused or coerced into unwanted sexual activity?

Yes
No

If Yes, By?

In any of your past relationship, have you been: Physically assaulted (hit,slapped, kicked, pushed, held down)?

Yes
No

If Yes, By?

The subject of demeaning, degrading comments or put downs?

Yes
No

If Yes, By?

Sexually abused or coerced into unwanted sexual activity?

Yes
No

If Yes, By?

REASONS FOR SEEKING COUNSELING

Check those that apply

PREVIOUS TREATMENT

Have you participated in therapy or counseling in the past?

Yes
No

If Yes, please specify:

Date

Duration

Therapist / Location

Was it Helpful?

Who do you turn for social support (E.g. for encouragement, advice, frienship, etc.)?

Are there any organization or agencies that you are currently receiving assistance or support from?

Yes
No

If Yes, please specify:

EXTENDED FAMILY HISTORY OF PHYSHOSOCIAL/HEALTH DIFFICULTIES

Please check any of the conditions below that are or have been present in your extended family. Please write any additional explanatory comments that may be helpful for your therapist to understand

Who? When?

OTHER INFORMATION

Please include here any additional background information you feel would be helpful for your therapist to know:

Patient Information

REASONS FOR SEEKING COUNSELING

PREVIOUS TREATMENT

EXTENDED FAMILY HISTORY OF PHYSHOSOCIAL/HEALTH DIFFICULTIES

OTHER INFORMATION

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