THERAPIST CLIENT INTAKE FORM

DISCLAIMER: Thank you for your interest in being a client of [CLINIC NAME]. This form is used to collect information about new clients and used for internal purposes only. The information you provide is confidential and will be treated accordingly.

CLIENT INFORMATION

Name: __________________ Birth Date: _______ Address: ____________________
Phone: ____________________ Is it okay to: ☐ Phone? ☐ Leave a message? ☐ Text?
Email: ___________________________ (Emails may not be confidential)

DEMOGRAPHIC INFORMATION

Gender: ☐ Female ☐ Male ☐ Transgender ☐ Other (specify) ____________________
Ethnicity: _____________________  ☐ Prefer not to answer
Sexual orientation: ☐ Bisexual ☐ Heterosexual ☐ Lesbian/gay ☐ Other
Relationship status: ☐ Single ☐ Partnered ☐ Married ☐ Separated ☐ Divorced
☐ Widowed ☐ Other (specify) ___________
Check the highest degree you’ve earned: ☐ GED ☐ High school
☐ Associate’s degree ☐ Bachelor’s degree ☐ Master’s degree ☐ Doctoral degree

HEALTH HISTORY

Primary care physician name: ______________________________
How is your physical health? ☐ Poor ☐ Unsatisfactory ☐ Satisfactory ☐ Excellent
Do you take medications, over-the-counter drugs, or supplements? ☐ Yes ☐ No
Have you ever been assessed for psychological or learning issues? ☐ Yes ☐ No
-If yes, please explain, including when and by whom, and the findings/diagnosis:
____________________________________________________________
Have you been prescribed psychiatric medication in the past? ☐ Yes ☐ No
-If yes, please list what medications, the dosage, and when taken:
____________________________________________________________
Have you ever been hospitalized for psychiatric reasons? ☐ Yes ☐ No

FAMILY AND SOCIAL INFORMATION

List the family members to whom you are close:
____________________________________________________________
Any family history of mental illness, substance abuse, or learning difficulties? ☐ Yes ☐ No

PRESENTING CONCERNS

Briefly describe what brings you to this clinic:
____________________________________________________________
Approximately how long have these concerns been bothering you?
☐ A week ☐ A month ☐ Few months ☐ A year ☐ Few years ☐ Most of my life
How much do these concerns interfere with your:
Daily routine: Very little – ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 – Severely
Emotional well-being: Very little – ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 – Severely
Relationships/activities: Very little – ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 – Severely

ACKNOWLEDGMENT

Signature: _________________________ Date: ___________
Printed Name: ____________________

Guardian Signature (if required): ________________________ Date: ___________
Printed Name: ____________________