Intake Form
The following is what will be reviewed during your intake, as well as an ACEs survey. You may fill out or not fill out as much as you wish prior to your intake. Showing you this is purely an attempt to be transparent and prepare individuals who like to know what they’re getting into before taking the plunge. During our intake, I may ask additional questions or clarify certain points, and if any question feels too personal it is perfectly fine to say “skip”, though it may become crucial to revisit that information at a later date. This form will provide the basis for treatment planning and gives both your therapist and yourself a basis to decide whether the relationship is a good fit. Answers are meant to be kept relatively short as the time allotted for intakes is not sufficient for detailed discussion. At that completion of your intake, you may review and sign the terms of service (which is mandatory for any treatment to begin) and request a full appointment to begin treatment. Note: completing an intake does not constitute an agreement of treatment; it is simply a pre-requisite to becoming a client.
Name and date of birth
Contact information, including specific phone numbers or email addresses you prefer to use for confidential communication
Insurance information
Sex assigned at birth, gender identity, and sexuality
Do you have a job and if so, how do you like it? How long have you been there?
Comfortable financially or struggling? If struggling, what’s going on?
Relationship status
If you have any partners, what is the experience of that/those relationship(s) like for you? Have any past partners had a significant impact (positive or negative) on you?
Do you have any caregiving duties and what is that like for you? (May apply to children, elderly, etc.)
What was your relationship like with your parents and/or step-parents in childhood and how has it changed over time?
Are your parents separated or divorced? If so, how has that impacted you?
Do you have a primary care provider?
Relevant medical history
List of current medications
Prescribing psychiatrist for medications (if any)
If you’ve had a therapist before, what was the experience(s) like? If you haven’t had a therapist, what are some questions, assumptions, fears, hopes you have about therapy?
Any family medical history that feels relevant to present issues?
Any family history of addiction or mental health issues?
Any family history of heritable medical issues?
What problems are happening in your life that you want to seek help with?
How deeply are those problems impacting your day-to-day life and ability to function?
How do you think these problems started and what have you done to try to cope with, mitigate them, or eliminate them?
Current drug and alcohol use?
Any history of addiction treatment?
Any past suicide attempts or psychiatric hospitalizations?
Any childhood events or conditions that may impact your presenting problem?
Any pending civil or criminal litigation, including divorce?
Online activity, including estimated time spent daily on social media, browsing, gaming, texting, work/school, and other activities. Does any aspect of your online activity worsen your mental health or inhibit functioning in ways you wish it wouldn’t?
We will go through checklist for chronic mental health symptoms that have lasted longer than six months, including appetite changes, difficulty concentrating, anxiety, depression, fatigue, self-harm, fear, hopelessness, etc. This would be the best time to bring up any past diagnoses and any symptoms that you struggle to name.
Current friendships and important relationships
History with religion in childhood and any current religion, belief, and/or spiritual practices, and the role they currently play in your life.
What is something you really want to happen this year?
What is something you frequently fear?
What are the sources of joy in your life?
What are your goals or hoped-for outcome(s) attending therapy sessions?