Intake Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Gender (identity)

Sexual Orientation

Children & number

In case of emergency contact (name, email, phone number)

Religion / Belief

Education level

Ocupation

Are you currently receiving psychiatric or psychological care?

Yes

No

Have you been in therapy before?

Yes, individual therapy

Yes, couples therapy

No

Have you previously taken psychiatric medication (antidepressants or other)?

Yes

No

What psychiatric medication do you take?

Health information

What is your current state of health?

Poor

Adequate

Good

Please list if you have any health isues

How many times a week do you exercise or play sport?

Do you have any problems related to eating habits or appetite?

No

Yes, I eat a lot

Yes, I eat very little

Yes, I restrict what I eat

Have you noticed a significant change in weight in the last 2 months?

Yes

No

Do you drink alcohol regularly?

Yes

No

In an average month, how many times do you drink 4 or more drinks in a 24-hour period?

If you answered yes to the previous question, which recreational drugs do you use?

Have you had suicidal thoughts recently?

Frequently

Occasionally

Rarely

Never

Have you had suicidal thoughts in the past?

Frequently

Occasionally

Rarely

Never

Are you currently in one (or more) romantic relationships?

Yes, in a monogamous relationship

Yes, in two or more non-monogamous relationships

No, I am not currently dating

If yes, how long have you been in (each)your relationship(s)?

On a scale of 1-10, how would you rate your relationship(s)?

In this year, have you experienced strong or stressful changes?

Other information

What do you consider your strengths?

What do you like most about yourself?

What would you like to achieve with the therapy?

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Intake Form

Health information

Other information

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