Intake form-Adult

Introductory Questionnaire For Therapy

This questionnaire is designed to build a foundation for therapy. By responding to these questions as thoroughly as you can, you will be:

• Helping me get to know you in a comprehensive way
• Providing a historical background for present concerns
• Highlighting your main concerns
• Clarifying current concerns
• Helping me to know what might be ruled out diagnostically
• Preparing to develop a therapeutic plan

Some questions may not pertain to you – simply draw a line through them. Please answer all questions that are applicable completely. If there is a question you do not wish to answer in writing, discuss that with me when we meet.

Name

DOB
Age
Address

City
Zip
Phone (home) (work)

(cell)

Email address

Emergency Contact Name

Phone

How were you referred?

Martial Status If Married, Spouse’s Name

Age
Occupation
Employer

Do you have children? Y__ N__ Stepchildren? Y__ N__ Grandchildren? Y___ N___
Name Gender Age
Name Gender Age Name Gender Age

Please state your main concern(s) in your own words:

Please indicate how distressing your concern is right now:
1 2 3 4 5 6 7 8 9 10
Mild Moderate Very Extreme Totally upsetting

When did this begin? Give dates if possible:

Please describe any events that you believe brought on this issue or that keep it going:

How have you tried to resolve this concern?
How was that helpful? What obstacles remain?
Have you been in therapy before or received any prior professional or support group assistance for your concern? If so, what was helpful at that time?

Number of siblings:
Name Age Closeness of relationship
Name Age Closeness of relationship
Name Age Closeness of relationship Name Age Closeness of relationship
Name Age Closeness of relationship
Other family members you feel contributed to your life in a significant way either bad or
good: Give name, relationship and describe:

Name Living? Y N Age Health
Occupation
If deceased: What was his age and cause of death?
What was your age at the time of his death?
Indicate any mental or physical problems your father has/had: Circle and/or describe
Depression Anxiety Other Mental Illness
Physical Illness Drinking problems Drug problems
Suicidal thoughts/attempts if yes/when?
Other

Name Living? Y N Age Health
Occupation
If deceased: What was her age and cause of death?
What was your age at the time of his death?

Indicate any mental or physical problems your mother has/had: Circle and/or describe
Depression Anxiety Other Mental Illness
Physical illness Drinking problems Drug problems
Suicidal thoughts/attempts if yes/when
Other

Are your parents currently married? Y N If no, has either of your parents remarried? Y N
How old were you when they were divorced or widowed?
Was either parent previously married? Y N

Your religion as a child As an adult
Church affiliation Pastor’s Name
How would your describe your current spiritual/religious experience?

Would you consider your faith a personal strength? Y N
If you have ever experienced spiritual abuse, please describe here:

Do you affiliate with a nationality or country of origin? Y N If yes, please describe:

Circle any of the following that applied during your childhood or adolescence to you or anyone in your family:
happy unhappy emotional issues eating disorder family problems physical abuse alcohol abuse sexual abuse verbal abuse legal problems drug abuse school problems medical problems financial problems abortion

If you circled any problems above, or there is something else not listed here, please explain:

If you were not raised by your biological parents, who helped raise you?
Between what ages/years?
Please describe your father’s (or father substitute’s) personality and his methods of discipline
(past & present):

How did he show affection and how often did he share his affection with you?

In what ways did he influence you or others members of the family?

Please describe your mother’s (or mother substitute’s) personality and her methods of
discipline (past & present):

How did she show affection and how often did she share her affection with you?

In what ways did she influence you or others members of the family?

What were the standard emotional overtones in your family while you were growing up?

Has any member of your family had significant problems? If yes, please describe:

Has any relative expressed suicidal thoughts or behaviors? If yes, please describe:

Has any relative had serious problems with the law? If yes, please describe:

What is your height? Weight? Describe any recent changes:

Do you have or have you ever had any of the following?
Illnesses or physical conditions Surgeries Unusual sensations
Unusual physical characteristics Troubling physical symptoms

Please describe anything circled above or if there is anything not listed:

Current medications:
Prescribed by:
Allergies (food, medication, environmental):

Name and phone number of your family physician:

Date of most recent complete physical examination: Results: How would you describe your overall health?

Please name the last completed grade/degree(s) and what school:
Specialized areas of study: Current educational activities:
Do you have a documented or suspected learning disability? Y N If yes, describe

What sort of work are you currently doing?
In what ways does your present work satisfy or not satisfy you? Please describe:

What were your past ambitions or dreams?
What are your current ambitions or dreams?
What kinds of hobbies or leisure do you enjoy or find relaxing?

Has there been any recent change to your interest in, frequency of participation in these
activities? Y N If yes, what is the reason?

Is your household income sufficient to live on? Y N
If your concerns include financial issues, please describe:

Please circle and describe any of the following behaviors that apply to you:

overeating odd behavior
phobic avoidance
aggressive behavior
vomiting nervous tic
insomnia
outbursts of temper
loss of control procrastination
smoking
laziness
drinking too much working too much
drug use
can’t keep a job
compulsions risk taker
impulsive reactions
eating problems
crying withdrawal
sleep disturbance

concentration problems
gambling
other

Have you been hospitalized for psychological or emotional problems? Y N If so, when and where?

Please describe your parents’ attitude toward sex:
Was sex discussed in your home?
When and how did you derive your first sexual knowledge?
When and how did you first be come aware of your own sexual impulses?

Have you experienced anxiety or guilt feelings arising out of sex or masturbation? Please
describe:

Are your first or subsequent sexual experiences relevant? Y N In what way?

Is your present sex life satisfactory? Please describe:

Please describe any sexual concerns not discussed above:

Whom do you include in the group you consider your “family”?

How would you describe your current family?
What are the prevailing emotional overtones in your family?

Are there any changes you’d like to see happen in your family?

How long did you know your spouse before your engagement? How long were you engaged? How long have you been married? Were either of you married before? If yes, please describe:

If previously married, for how long? How soon were you remarried? How would you describe your relationship with your spouse?

Do you make friends easily? Y N How are your friendships important to you?

Rate the degree to which you generally feel comfortable and relaxed in social situations:
1 2 3 4 5 6 7 8 9 10

Very relaxed Relatively comfortable Uncomfortable Very anxious

Check any of the following that apply. Please indicate those you consider important, and those occurring over the past six years.

Death in the family
Miscarriage
Divorce
Trouble with the law
Financial trouble
Job/School problems
Serious illness
Serious operation
Abortion
Mental illness
Alcohol problems
Drug problems
Interpersonal problems
Sexual abuse
Depression
Physical abuse
Suicidal thoughts
Suicidal attempts
Spiritual problems
Anger management Unresolved conflict

Please describe if you circled any of the above. Indicate the person involved such as a spouse,
child, father, mother, brother, sister, yourself, etc.:

Other Influences (outside of your immediate family)

How do you relate with your in-laws?
Have your parents, relatives, or friends sought to influence your situation? Y N
Please describe:

Is your job or school situation unusually stressful? Y N
Please describe:

Please describe:
Have the police or other social agencies influenced your family? Y N
Please describe:
Have there been any other significant outside influences on your family? Y N
Please describe:

In a few words, what do you think therapy is all about?

How long do you think therapy should last?
How do you think a therapist should interact with clients?

How would you describe a desired outcome for therapy?

Please use this area to describe any other related matters you may have that have not been addressed by this questionnaire.

The information contained herein is complete and truthful to the best of my ability.
Signature Date

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