Therapy Intake Form

Please provide the following information for my records. You may leave blank any question you would rather not answer.

The information you provide here is held to the same standards of confidentiality as our therapy.

If any given question does not apply to you, please put down “n/a” or “none.”

Patient Info / Background
Name*
First Last
Date of Birth*
MM
DD
YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Cell Phone*
May I leave a message?*
- Yes
- No
Home Phone
May I leave a message?
- Yes
- No
Email*
Enter Email Confirm Email
Age*
Gender
Marital Status
Number of Children
Who referred you to this practice?
Are you currently in treatment with another mental health provider?
Are you currently on any psychotropic medication (e.g. antidepressants, etc.)?
If so, what are you currently taking? (please list medication name and dose)?
Who is prescribing these medications for you?
If you are not currently on psychotropic medication but you have been in the past, what were you on and who prescribed this for you?
Have you had psychotherapy/counseling before? If so, who with?
Are you on any medication at all (not just psychiatric)? If so, what and how much (and what is it treating)?
Health / Social / Legal History
How is your physical health?
Any chronic physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.)?
Any sleep problems? If so, please describe:
Do you have a regular wellness/exercise routine? If so, please describe:
Any problems with appetite or eating? If so, please describe:
Do you regularly use alcohol? Other substances? If so, please describe (what, how often, how much).
Have you ever been arrested/convicted/any D.U.I.s? If so, please describe:
Do you ever thinking about killing yourself? Have you ever attempted to kill yourself? Please, describe:
Are you having any relational problems? If so, please describe:
What stresses you out at present/currently? Please, describe:
Have you ever experienced any of the following? (Please check all that apply.)
- Select All
- Extreme depressed mood
- Wild mood swings
- Rapid speech
- Extreme Anxiety
- Panic attacks
- Phobias
- Sleep disturbances / hallucinations
- Unexplained losses of time
- Unexplained memory lapses
- Alcohol / substance abuse
- Frequent body complaints
- Eating disorders
- Body image problems
- Repetitive thoughts (e.g. obsessions)
- Repetitive behaviors (e.g. frequent checking, hand-washing, etc.)
- Homicidal thoughts
- Suicide attempt
Hospitalization History
Have you ever been psychiatrically hospitalized? If so, was it voluntarily? Or was it involuntarily? When/where? Please, describe:
When did the current symptoms start to surface?
Was there a precipitating event (death, loss, break up, financial issues, etc) or did the symptoms seem to happen without provocation?
Professional / Occupational History
What is your education level?
What do you do for living?
Family Mental Health History
Has any member of your immediate family received any psychiatric/psychological treatment? If so, please, describe (for what problem, what type of treatment)?
Other Information
What is your first childhood memory? Please provide details such as who, what, when, etc.
If you had to describe your mother in one word, what would it be?
And now your father?
How do you feel about yourself?
How do you cope with moderate to severe stress?
How do you respond to grief, loss, and/or disappointment?
What do you hope to get from therapy?
What do you read?
What do you watch on TV?
Do you have a meditation practice?
What, if any, is your religious/spiritual background?
Diet / Lifestyle / Nutrition
Please provide basic information about your daily diet. Do you have food allergies? If so, what are they? Do you drink caffeine? If so, what type and how much? Do you eat processed foods? If so, provide examples.
Were you breastfed or bottle fed as an infant? (If you do not know, please indicate that.)
Are you vegetarian?
- Yes
- No
If so, do you take vitamin B 12 supplement? If yes, what form (oral, iv, sublingual)?
Do you take omega-3 fatty acid supplements? If yes, how much per day?
Do you eat/drink dairy? If yes, how much per day?
Do you eat gluten? If yes, how much per day?
Have you had your thyroid tested in the last 6 months? If yes, please provide me with a copy of those results.
What types of food do you crave?
- Sweet
- Savory
- Both
Do you feel you have ample restraint to refrain from these cravings or do they feel out of your control?
What was the culture of food in your household growing up?
Do you suffer from eczema, rashes, etc.? If so, do you recall the treatment?
Did you ever suffer from chronic ear infections? If so, do you recall how often you were put on antibiotics?
Did you struggle with attention related issues in elementary school? Or hyperactivity? If so, how did your school and family help you to manage these symptoms?
Is there anything else you feel I should know related to how nutrition and food impacts your life?

Patient Info / Background

Health / Social / Legal History

Hospitalization History

Professional / Occupational History

Family Mental Health History

Other Information

Diet / Lifestyle / Nutrition

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