New Client Intake Name DOB MM DD YYYY Age Gender Pronouns Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation/Employer Emergency Contact Name, relationship, phone number Primary Care Physician and phone number What are your goals for therapy at this time? Have you received counseling/therapy in the past? Yes No Have you ever been hospitalized for a psychiatric issue? Yes No Please describe any known family history of mental illness: Please list any health problems you are experiencing: Please list any supplements or medications you are currently taking: Please include name, strength, and intended purpose What is your current living situation? Please list any significant life changes or stressful events you have recently experienced: Have you ever experienced, witnessed, or been confronted with an event involving actual or threatened death, serious injury, or other harm to self or others? Yes No How often do you drink alcohol? How often do you use recreational drugs? Please indicate if you are experiencing any of the following symptoms: Impulsivity Trouble concentrating Hopelessness Tearfulness or crying spells Low self-worth Recurring, disturbing memories Change in appetite Isolation from others Anxiety Panic Phobias Obsessive thoughts Compulsive behaviors Mood swings Paranoia/suspicions Aggression Homicidal/violent thoughts Irritability/anger Insomnia Excessive sleep Lack of motivation Manipulative behavior Are you currently having thoughts of suicide? Have you ever attempted to end your life? Yes No Any other information you would like me to know? Thank you!
