CONFIDENTIAL

This intake form is to be completed by all new clients. The answers you provide will become part of your
confidential records. Should you have any queries, or require assistance with any of the below questions,
please feel free to ask your therapist.

 
First Name Last Name
Date of Birth  
Address
Postcode  
Home Tel. No. Work Tel. No.
Mobile Tel. No. Email
Have you had any previous treatment for psychological issues?
YesNo
If yes, please give details - i.e. when, where, how long, provider name, medications etc
Are you currently taking (or in the recent past, taken) any prescription or over-the-counter medications?
YesNo
If yes, please give details:
Does anyone in your family (blood relatives) suffer with any psychological problems?
YesNo
If yes, please give details:
Do you drink alcohol?
YesNo
If yes, please give details – how much, how often, any blackouts, etc
Do you use any recreational drugs?
YesNo
If yes, please give details – what drugs, how often, last use etc.
Have you ever suffered from any type of eating disorder?
YesNo
If yes, please give details:
Do you have any work-related problems / difficulties in school?
YesNo
If yes, please give details:
Do you have a history of trauma (any kind of abuse, neglect, victim of natural or other disaster etc)?
YesNo
If yes, please give details:

Symptoms Checklist

Sleep: No problemNot enoughTrouble getting up NightmaresToo much sleep
Appetite: No problemsNo interestIncreased appetite Carbohydrate craving
Energy: NormalIncreasedLowUp and down
Interest in Sex: NormalIncreasedLow
Concentration: NormalSomewhat difficultPoorTerrible
Memory: GoodSome difficulty rememberingPoor
Depressed or sad: All the timeMost daysSome daysNot at all
Suicidal thoughts: All the timeMost daysSome daysNot at all
Past suicide attempts?
YesNo
If yes, please give details:
Anxiety: All the timeMost daysSome daysNot at all
Panic Attacks: FrequentlyOccasionallyNot at all
Anger/Irritation: All the timeMost daysSome daysNot at all
Any other Comments: