Client Intake Form Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information. Please fill out this form before your first session. Client Name First Client Last Name Last Name of parent/guardian (if under 18 years): Parent Name First Parent Last Name Last Date of Birth Age Gender MaleFemale Marital Status Never MarriedDomestic PartnershipMarriedSeperatedDivorcedWidowed Please list any children/age: Address City Post Code State ACTNew South WalesNorthern TerritoryQueenslandSouth AustraliaWestern AustraliaVictoria Home Phone May we leave a message? Yes No Home Phone May we leave a message? Yes No Email Address May we email you? Yes No *Please note: Email correspondence is not considered to be a confidential medium of communication. Referred by (if any) Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No Who was your previous therapist/practitioner? Are you currently taking any prescription medication? Yes No Please list: Have you ever been prescribed psychiatric medication? Yes No Please list and provide dates: GENERAL HEALTH AND MENTAL HEALTH INFORMATION arrowup6 How would you rate your current physical health? Poor Unsatisfactory Satisfactory Good Very good Please list any specific health problems you are currently experiencing: How would you rate your sleeping habits? Poor Unsatisfactory Satisfactory Good Very good Please list any specific sleep problems you are currently experiencing: How many times per week do you generally exercise? What types of exercise to you participate in? Please list any difficulties you experience with your appetite or eating patterns Are you currently experiencing overwhelming sadness, grief or depression? Yes No For approximately how long? Are you currently experiencing anxiety, panic attacks or have any phobias? Yes No Please describe. Do you drink alcohol more than once a week? Yes No How often do you engage recreational drug use? DailyWeeklyMonthlyInfrequentlyNever Are you currently in a romantic relationship? Yes No For how long? On a scale of 1-10, how would you rate your relationship? What significant life changes or stressful events have you experienced recently: FAMILY MENTAL HEALTH HISTORY: arrowup6 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 (father, grandmother, uncle, etc.). Alcohol/Substance Abuse Yes No Family member Anxiety Yes No Family member Depression Yes No Family member Domestic Violence Yes No Family member Eating Disorders Yes No Family member Obesity Yes No Family member Obsessive Compulsive Behavior Yes No Family member Schizophrenia Yes No Family member Suicide Attempts Yes No Family member ADDITIONAL INFORMATION arrowup6 Are you currently employed? Yes No What is your current employment situation? Do you enjoy your work? Is there anything stressful about your current work? Do you consider yourself to be spiritual or religious? Yes No Describe your faith or belief. What do you consider to be some of your strengths? What do you consider to be some of your weakness? What would you like to accomplish out of your time in therapy? Please leave this blank
