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Client Intake Form for Mental Health

The document is a client intake form designed for gathering personal and health information from individuals seeking therapy. It includes sections for demographic details, mental health history, current psychological services, and general health information. The form emphasizes confidentiality and estimates a completion time of approximately 30 minutes.

Uploaded by

Amarachi Cecilia
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62 views2 pages

Client Intake Form for Mental Health

The document is a client intake form designed for gathering personal and health information from individuals seeking therapy. It includes sections for demographic details, mental health history, current psychological services, and general health information. The form emphasizes confidentiality and estimates a completion time of approximately 30 minutes.

Uploaded by

Amarachi Cecilia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Section 1: Intake forms

CLIENT INTAKE FORM

Please answer the following questions to the best of your abilities. This information is held
to the same standards of confidentiality as our therapy sessions. This questionnaire will take
approximately 30 minutes to complete.

Name:
(Last) (First) (Middle initial)

Name of parent or guardian (if minor):

Birth date: / / Age:

Gender: Male Female Other:

Marital status: Single Partnered Married Separated Divorced

Widowed Number of children: Ages:

Home address:

City: State: Zip code:

Home phone: May we leave a message? Yes / No

Cell/other: May we leave a message? Yes / No

Email: May we email you?* Yes /No

Referred by:

Are you currently receiving psychological services, professional counseling, psychiatric


services, or any other mental health services? Yes / No

Reason for change:

Have you had any mental health services in the past? Yes / No

Reason for change:


Are you currently taking any psychiatric prescription medication? Yes / No

If yes, please list:

Have you been prescribed psychiatric prescription medication in the past? Yes / No

If yes, please list:

General Health Information

How would you describe your physical health at the present time?
Poor Unsatisfactory Satisfactory Good Very good

Please list any persistent physical symptoms or health concerns (e.g., chronic pain,
headaches, hypertension, diabetes, thyroid dysfunction, etc.):

Are you on any medication for physical/medical issues? Yes / No

If yes, please list:

Are you having any problems with your quality of sleep? Yes / No If yes, check those that

apply:

Sleep too much Sleep too little Poor quality Disturbing dreams

Other:

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