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:

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