Intake Form | My Site 2

First name

Last name

Birthday

Month

Day

Year

Phone

Address

Presenting Problem (motivation for services):

Immediate Alerts:

(suicidal, homicidal, violence, abuse, or N/A)

Development of the present problem(s), (onset & duration):

Have you had previous counseling or psychotherapy?

Yes

If yes, please give dates, length of therapy, frequency, and name of therapist. Was therapy helpful?

Childhood & Family History:

(Please describe any significant events, i.e., constant moving, separations, death in the family, etc.?)

Immediate Family Members and Ages:

Is there a family history of mental illness/substance abuse?

If no, please put N/A

Briefly describe current and past relationship(s) (include sexual orientation):

History of physical or sexual abuse?

Reported? By whom? (Are there currently any children in danger?)

Psychiatric Hospitalizations:

If none, please put N/A

Current and Past Alcohol/Drug Use and/or Treatment:

If none, please put N/A

Medical Problems:

Current/Past Medications:

Educational History:

(include academic achievement, behavior, special classes, etc.)

Current and Past Work Situation:

(length of employment, job satisfaction, relationship with co-workers)

Motivation for Therapy

rate on a scale of 1 (low) to 10 (high)

Therapy Outcome Desire: