New Client Form

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Client Intake Questionnaire

Please fill in the information below and bring it with you to your first session. Please note: information provided on this form is protected as confidential information. Personal Information

Name

Date

Parent/Legal Guardian (if under 18):

Address:

Home Phone:

May we leave a message?

Yes No

Cell/Work/Other Phone:

May we leave a message?

Yes No

May we leave a message?

Yes No

DOB:

Age:

Gender:

Spouse/Partner Name:

Do you want information shared with your spouse?

Yes No

Referred by (if any):

Have you previously received any type of mental health services (psychotherapy, psychiatric services)?

Yes No

Previous therapist/practiioner:

Are you currently taking any prescription medications?

Yes No

If yes, please list:

Have you ever been prescribed psychiatric medication?

Yes No

If yes, please list & provide dates:

General and Mental Health information

How would you rate your current physical health?

Please list any specific health problems you are currently experiencing:

Please list any specific sleep problems you are currently experiencing?

How many times per week do you generally exersize?

What types of exersize do you participate in?

Please list any difficulties you experience with your appetite or eating problems:

Are you currently experiencing overwhelming sadness, grief or depression?

Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks or having any phobias?

Yes No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Yes No

If yes, please describe:

Do you drink alcohol more than once a week?

Yes No

Are you currently in a romantic relationship?

Yes No

If yes, for how long?

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?

What significant life changes or stressful events have you experienced lately?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (e.g. father, grandmother, uncle, etc.).

Alcohol /Substance Abuse

Yes No

Anxiety

Yes No

Depression

Yes No

Domestic Violence

Yes No

Eating Disorders

Yes No

Obesity

Yes No

Obsessive Compulsive Behavior

Yes No

Schizophrenia

Yes No

Suicide Attempts

Yes No

Additional Information

Are you currently employed?

Yes No

If yes, what is your current employment?

Do you enjoy your work?

Is there anything stressful about your work?

Do you consider yourself to be spiritual or religious?

Yes No

If yes, please describe your faith or belief:

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy?

801-260-2016
459 E 1000 S, Pleasant Grove, UT 84062
682 W Hwy 198, Salem, UT 84653