ADULT CLIENT INTAKE FORM
*
Name of Client:
First Name
Last Name
Date of Birth
*
Address
*
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Email
*
Occupation
*
Education
*
Marital Status
*
Partner / Significant Other
Address
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Cell Phone
(###)
###
####
Email
Occupation
Children (include their ages)
Who lives in your home?
*
Who referred you?
YOUR MEDICAL HISTORY
*
List any illnesses, major injuries, and/or surgeries, and any allergies.
Who is your primary care provider?
*
What is the date of your last physical?
*
MM
DD
YYYY
List all Medications
*
Include dosage and name of prescriber.
Caffeine
*
Tobacco
*
Illicit Drugs
*
Self-Injurious Behavior
*
Suicidal Ideation
*
Disordered Eating
*
Please list all past hospitalizations including medical, psychiatric, and chemical dependency.
*
For each, include date, reason and hospital or facility.
Previous Psychotherapy
*
Please list for each: 1) the facility/therapist name, 2) dates seen, and 3) whether it was helpful or not helpful.
Have you tried any other strategies previously?
*
Examples: Tai Chi, Qigong, medication, yoga, acupuncture, massage, etc.
Family History
*
Describe any psychiatric problems, drug abuse, or alcoholism in immediate and extended family.
Your Support Systems
*
Examples: extended family members, community agencies, religious institutions, etc.
How is your sleep and appetite?
*
Do you exercise? If so, what do you do and how often?
*
What concerns bring you this office?
*
What changes do you want to make in your life?
*
Additional Remarks
*
Please provide any additional comments you wish to make regarding your difficulties.
