New Client Intake Form

Last Name

First Name

Date of Birth

Age

Home Phone

Ok to Leave Message? Ok to Leave Message? Yes No

Cell/Other

Email Address

Employment/Education Information Employment/Education InformationYesNoStudentHomemakerRetired

If you are employed, who is your current employer and how long have you been there?

Do you enjoy your work? Is there anything stressful about your work?

What is the highest level of education you completed?

List any major illnesses, hospitalizations, or accidents you have had and what age they occurred?

What substances do you or have you used in the past? (Please include recreational use of alcohol and tobacco)

How often and how much?

Do you consider any of the using to be a problem?

Have you received any help for chemical dependency?

Who were you raised by?

Did your parents work? If so what was/is their occupation?

If your parents were divorced/separated did either remarry or repartner?

In your opinion, did your parents have a good relationship with each other?

Did you have a good relationship with them/siblings?

Were you disciplined a a child? If so, how?

Who currently lives in your home?

If there are children in your home, how is discipline handled?

Please list the members of your current family including parents, siblings, and children ages and be sure to include if they are biological, adoptive, or other.

Please check any that apply to you or your family members:

Emotional Problems Emotional Problems Yes No

Alcohol/Drug Abuse Alcohol/Drug Abuse Yes No

Psychiatric Hospitalization Psychiatric Hospitalization Yes No

Anxiety Anxiety Yes No

Depression Depression Yes No

Other Mental Illness Other Mental Illness Yes No

Suicide Attempts Suicide Attempts Yes No

Serious Physical Illness Serious Physical Illness Yes No

Weight/Eating Issues Weight/Eating Issues Yes No

Physical Abuse Physical Abuse Yes No

Sexual Abuse Sexual Abuse Yes No

Learning Problems Learning Problems Yes No

Deaths Deaths Yes No

Divorce Divorce Yes No

Legal Issues Legal Issues Yes No

Financial Crisis Financial Crisis Yes No

Other Other Yes No

If you answered yes to any of the above, please specify.

How much is your family a source of emotional support for you? How much is your family a source of emotional support for you?NoneLittleSomewhatSubstantialVery Strong

Whould you consider yourself to be spiritual/religious? Please describe:

Relationship Status (check all that apply) Relationship Status (check all that apply) Married/Committed Separated Divorced Dating Living Together Living Apart

Length of time in current relationship:

On a scale of 1-10, how would you rate your relationship? Why?

Please list any concerns in your current relationship.

Please list any previous relationships that may be of concern and why.

What do you consider some of your strengths?

Additional info you would like to share:

Please list any medications you are taking.