Client Forms-First Visit Intake

Client Questionnaire–please print out and bring to the first scheduled session

Name:_________________________________Age_________Date of Birth_____________

Mailing Address_________________________________________________________

________________________________________________________________________

Phones:  Call first: ________________________Email ____________________________

Emergency Contact:{Name/Telephone} ___________________________________________

Please answer any of the following questions that apply to you.  This will help to focus on your primary concerns and establish goals for our work. Please use additional space as needed.  We will go over areas of importance in detail when we meet.

  1. Do you have any specific medical conditions that are current or chronic ?

 

________________________________________________________________________________________________________________________________________________

 

  1. Are you now, or have you been, on any medications for psychological reasons?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

  1. What are your current medications or supplements?

________________________________________________________________________________________________________________________________________________

 

 

Medication Dosage/

frequency

Reason

Dates- Start/stop

Prescribed by MD  [name] or OTC
         
         
         
         
         
  1. 4.     What is your daily/weekly consumption of alcohol?  Do you, or does someone connected to you, have concerns about the use of alcohol?  Other substances?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  1. 5.     Who was in your home/family growing up? {Parents, step parents, siblings] [Names, ages, relationship.]

Name_____________Relationship______Age_[Older/younger by [years]__/DOB

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________use last page

 

  1. 6.     Do you have children, step children, pets?

Name_____________Relationship____                                           __Age

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________use last page

 

  1. Who lives with you now? Name_____________Relationship______Age_[Older/younger by [years]__/DOB   ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

  1. Have there been changes in your eating, sleeping or general heath in the past 6 months? Do you have concerns about your eating or sleeping patterns?   Please describe.  ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  2. Why did you pick Laura Shlien as a therapist—referral, website, insurance?

______________________________________________________________________________________________________________________________________________________

  1. Have you had suicidal thoughts, now or in the past?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

 

  1. Check any of the following that you experience.
  Cultural issuest     Financial stress
  Lack of appetite     Difficulty Concentrating
  Increased in appetite     Unable to complete tasks
  Anxiety /Nervousness     Intrusive thoughts
  Panic Attacks     Socially Isolated
  Fears/ Phobias     Flashbacks
  Obsessive thoughts     Hearing voices others cannot hear
  Compulsive behaviors     Seeing images others do not see
  Difficulty relaxing     Difficulty trusting
  Difficulty falling asleep     Anger management
  Interrupted sleep     Domestic Violence [Past/present]
  Sleeping too much     Victim  of Violence [Past/present]
  Nightmares     Increased alcohol use
  Fatigue     Alcohol abuse or dependency
  Depression     Drug abuse or dependency
  Low Self-esteem     Eating disorder [past/present]
  Thoughts/plans for suicide     Self harm behavior
  Suicide Attempts     Marital issues
  Mood swings     Family issues with children
  Stomach problems     Family issues with parents
  Headaches     Work Issues
  Chronic Pain     Personal growth
  Spiritual issues     Existential issues
  Fear of death /dying, self or other     Issues not listed
  1. Have you worked on these issues in therapy before? When, with whom?  Was therapy helpful?

 

  1. What are your goals for therapy now?

 

 

  1. What would change if therapy is successful?

 

 

  1. Who do you go to for support?

 

 

  1.  List 5 experiences that changed your life,  in a positive or a negative way.

 

 

 

 


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