Client Intake Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile/Cell Phone *

Country

(###)

###

####

Work Phone

Country

(###)

###

####

Home Phone

Country

(###)

###

####

Date of Birth *

MM

DD

YYYY

Have you previously received any type of mental health services? *

Check all that apply. (eg: psychotherapy, psychiatric services, etc)

Individual

Couples

Family

Group

Psychiatric

Other

N/A

How would you rate your current physical health? *

Poor

Unsatisfactory Satisfactory

Good

Excellent

How would you rate your current sleeping habits? *

Poor

Unsatisfactory

Satisfactory

Good

Very Good

Family History *

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (father, grandmother, uncle, etc) Check all that apply

N/A

Alcoholism

Substance Abuse

Depression

Anxiety

Domestic Violence

Eating Disorders

Obesity

Obsessive Compulsive Behavior

Schizophrenia

Bi-Polar/Manic Depression

Suicide Attempts

Indicate the kind of therapy you are requesting *

Check all that apply

Individuals

Couples

Family

Group

Imago