intake questionnaireplease complete the intake questions with as much detail as you feel comfortable Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday MM DD YYYY Emergency Contact First Name Last Name Phone (###) ### #### What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can. What are your goals for counseling? Have you seen a mental health professional before? Yes No Specify all medications and supplements you are presently taking and for what reason. If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number. Who is your primary care physician? Please include type of MD, name and phone number. What is your gender identity? Female Male Non-binary/Genderqueer Prefer not to disclose Other What are your preferred pronouns (ex: she/her, they/them etc.)? What is your sexual orientation/identity? Aromantic Asexual Bisexual Fluid Gay Lesbian Pansexual Queer Questioning/Unsure Same-gender-loving Straight (heterosexual) Prefer not to disclose Other Do you drink alcohol? Yes No Do you use recreational drugs? Yes No Do you have suicidal thoughts? Yes No If yes please explain Have you ever attempted suicide? Yes No If yes please explain Have you ever been hospitalized for a psychiatric issue? Yes No If yes please explain Is there a history of mental illness in your family? Yes No If yes please explain If you are in a relationship, please describe the nature of the relationship and months or years together. Describe your current living situation. Do you live alone, with others. With family, etc... What is your level of education? Highest grade/degree and type of degree. What is your current occupation? What do you do? How long have you been doing it? Please check any of the following you have experienced in the past six months Increased appetite Decreased appetite Trouble concentrating Difficulty sleeping Excessive sleep Low motivation Isolation from others Fatigue/low energy Low self-esteem Depressed mood Tearful or crying spells Anxiety Fear Hopelessness Panic Thank you!
