Psychology Intake Form

Who is seeking services?

Self
Couple

Personal Information of Counseling Person

Preferred Name / Nickname *

First

Last

Legal Name

Prefix

First Name

Middle Name

Last Name

Date of Birth

Gender

Male
Female
Non-Binary/Non-conforming
Transgender
Prefer not to response
Other

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Highest Level of Education

Military Service (type/dates)

What is your occupation/career/profession? Please indicate your current level of satisfaction:

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Email *

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

Name *

First

Last

Relationship to Emergency Contact

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Email *

Phone

Relationship Status

Single Roommates
Cohabitants/Life Partners
Common Law/de Facto
Married
Separated
Divorced/Dissolution
Roommates
Other

If you have children, please list names and ages.

Please describe your social support network including who you consider supports and who you consider to be a drain on your well being:

Previous Psychological/Psychiatric services

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Individual Psychotherapy

Individual Psychotherapy

Length of Therapy

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Couples Therapy

Couples Therapy

Length of Therapy

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Group Therapy

Group Therapy

Length of Therapy (copy)

Length of Therapy

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Medication1

Medication 1

Medication1_Names_Dates

Medication Name/Dates

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Medication2

Medication 2

Medication2_Names_Dates

Medication Names/Dates

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PsychiatricHospitalizations

Psychiatric Hospitalizations

PsychiatricHospitalizationsDates

Dates/Facility

In your own words, describe your experience with psychological/psychiatric services. What has been effective and what has not worked?

What have you found helpful for managing stress, conflicts, and relationships?

Describe in your own words, what brings you in today:

How long has this been going on?

What made you decide to come in at this time?

What do you hope to gain from this therapeutic experience?

Issues of Concern

Please check all issues that are applicable

Abuse
Addiction
Adjustment
Ageing
Anger
Anxiety
Depression
Displacement
Couple/Family
Creativity
Grief & Loss
Gender Dimension
Loneliness
Obsessive Compulsive
Panic Attacks
Parenting
Post-Traumatic Stress
Relationship
Self-Harm
Sexual Issues
Sleeping
Stress
Suicidal Thoughts
Trauma
Body Image
Work Stress
Women's Health
Long COVID/ME/CFS
Identity
Existential Angst
Art and Cultural
Highly Sensitive Person
Leadership/Motivation
Self-esteem
Transformation
Other

Please describe any details you would like me to know about the issues you have selected:

Please specify any medical/allied health services who are involved in your care:

Please specify all ongoing medical diagnoses:

Please list any prior (significant) illnesses, surgeries, and/or accidents (with dates):

Please specify all current medications:

Please check all you have experiences in the last 1-2 months

Anger
Anxiety
Avoidance
Behavioral Changes
Breathlessness
Changes in eating patterns
Concentration/focus or other cognitive issues
Connection to others
Creativity
Delight
Dizziness
Depressed Mood
Difficulty leaving home
Fatigue
Fight-or-Flight
Hallucinations
Hopelessness
Intrusive Thoughts/memories
Irritability
Joy
Muscle tension or weakness
Numbness
Panic
Obsessive thinking
Peace of mind
Racing thoughts
Self-harm
Suicidal thinking
Suicidal attempt
Sleep disruption
Social support
Tremors
Unrealtiy
Worthlessess
Worry
Other

Describe activities that bring you joy, fulfillment, and/or a sense of balance and frequency of engagement:

Please specify any ongoing treatments in which you are currently engaged:

Indicate that you are giving permission for communication with the following persons/agencies:

Please specify any concerns or comments you would like me to know about:

Referral Information

How did you learn about our services?

General Practitioner
Specialist
Family or friend
Social Media
Internet Search
Other

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Referrer Name

First

Last

Referral Date

AgreeToTerms

I agree to the terms and conditions

Date *

Signature *