Intake Assessment

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Why are you seeking help now? *

Have you seen a mental health professional before? *

Have you ever been hospitalized for a psychiatric issue? *

Has anyone in your family ever sought help for or experienced mental health or substance use issues? *

Do you have any current or prior medical issues? *

Are you currently prescribed any medications? *

Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed? *

Who is in your family? What is your relationship with them like? *

What social activities and relationships do you engage in? *

What spiritual practices and cultural influences are important to you? *

What was life like as you were growing up, both at home and in school? *

What significant education and work/volunteer experiences have you had? *

What is your current occupation? What do you do? How long have you been doing it? *

Describe your current living situation. Do you live alone, with others, with family? *

Do you have any current or prior legal issues? *

What strengths and abilities are you bringing to sessions? What needs or preferences do you have that will help us be successful? *

What else would you like me to know? *

Please list an emergency contact (name, relationship, and phone number) *

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