May 12 2008
Intake form (Best to use Mozilla Firefox Browser)
Intake form
Complete these questions prior to our first session if possible. If this is for couples therapy, each person should complete this form.
Please note that you it is best to access this form via the Mozilla Firefox browser (click here for free download) and then can copy and paste this form into a Word document. Use as much space as you need.
Name:
Address:
Phone: home cell work
Birthdate:
Insurance information:
Name:
Identification number:
Group number:
Customer service telephone number:
Claim address:
Why you are considering therapy right now?
What are your most important concerns?
If you had a magic wand, what would you wish for right now?
If this is for couples therapy, what are the major issues to focus on right away?
Have you ever utilized therapy before? What was your experience?
Have you used anti-depressant medication or other medications before? Please specify what, when and dosage.
Describe any concerns you have related to the following:
Thinking/concentration
Ability to focus
Complete tasks
Rapid heart beat
Panic attacks
Fears
Sleep
Eating
Anxiety
Depression
Low self-esteem
Sexual relations
Sexual orientation
Sexual identity
Suicidal thoughts or attempts
Homicidal thoughts or attempts
If you use alcohol or other drugs, describe your routine use. Be detailed.
Also, go to alcohol screening.org, complete the survey, add your score here:
Describe the family in which you were raised.
What were the major issues of concern in your family?
Who were you emotionally close to and emotionally separate from? Why?
How was the communication in your family?
Describe any times in your life where you felt mistreated or abused in any way. Start from when you first remember until the present time.
Go to the structured writing exercises and explore other questions which may relate to you.
Go to the help for Chicago marriages (relationships) category and explore some of those posts for help in either understanding a problem or finding a solution.
What else would you like to say about yourself, family or other significant relationships?