Adult Clinical Intake Form
Today’s Date: ____/____/________
Please provide the information below for our records. The information provided here will be held to the
same standard of privacy and confidentiality as our therapy sessions. Feel free to leave blank any
question you prefer not to answer. For your convenience, you can either print this form and bring to
our initial session, or arrive fifteen minutes early to complete this form in the office.
Name ______________________________________________Date of Birth _________________________
Address
___________________________________________________________________________________
May we send mail to this address: ☐ yes ☐no
Email Address: ___________________________________ Is it ok to email you? ☐ yes ☐ no
Phone (_____)____________________________ Is it ok to leave a voicemail? ☐ yes ☐ no
Is it ok to leave a text ? ☐ yes ☐ no
Emergency Contact
Name ___________________________________________ Phone (____)________________________
Email _____________________________________________ Relationship _________________________
Relationship Status
☐ single ☐ partnered ☐ married ☐ separated ☐ divorced ☐ widowed
Length of time in current relationship: _______________________________________________________
Do you have children? □No □Yes If yes, how many?: _____ Ages: _________________________
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Health Information
How is your current physical health? (please circle)
Poor Unsatisfactory Satisfactory Good Very good
Primary Care doctor:_____________________________ _________________________________
(Name) (Phone)
Please list any chronic health problems or concerns (e.g. asthma, hypertension, diabetes,
headaches, stomach pain, seizures, etc.):
_______________________________________________________________________________
Medications:_____________________________________________________________________
Are you having any problems with your sleep habits? □ No □ Yes
If yes, check where applicable:
□ Sleeping too little □ Sleeping too much □ Can’t fall asleep □ Can’t stay asleep
Do you exercise regularly? □ No □ Yes
If yes, how many times per week do you exercise? ______ For how long? ______________
If yes, what do you do?_______________________________________________________
Are you having any difficulty with appetite or eating habits? □ No □ Yes
If yes, check where applicable: □ Eating less □ Eating more □ Bingeing □ Purging
Have you experienced significant weight change in the last 2 months? □ No □ Yes
Do you regularly use alcohol? □ No □ Yes
If yes, what is your frequency?
□ once a month □ once a week □ daily □ daily, 3 or more □ intoxicated daily
How often do you engage in recreational drug use? □ Daily □ Weekly □ Monthly □ Rarely □ Never
If you checked any box other than “never,” which drugs do you use?
_________________________________________________________________________
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Do you smoke cigarettes? □ No □ Yes
If yes, how many cigarettes per day?________________
Do you drink caffeinated drinks? □ No □ Yes
If yes, # of sodas per day______ cups of coffee per day_______
Have you ever had a head injury? □ No □ Yes
If yes, when and what happened?_______________________________________________
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Mental Health History
Have you had previous psychotherapy? □No □Yes
If yes, why?_________________________________________________________________
If yes, when?_______________________________________________________________
If yes, with who?_____________________________________________________________
Are you currently taking prescribed psychiatric medications (antidepressants or others)? □Yes □No
If Yes, please list names and doses: _____________________________________________
If No, have you been previously prescribed psychiatric medication? □Yes □No
If Yes, please list names and dates: ________________________________________
Are you currently experiencing: Rating Scale 1-10 (10 =worst)
Only rate the areas to which you say “yes”
Depressed Mood or Sadness yes no ______
Irritability/Anger yes no ______
Mood Swings yes no ______
Rapid Speech yes no ______
Racing Thoughts yes no ______
Anxiety yes no ______
Constant Worry yes no ______
Panic Attacks yes no ______
Phobias yes no ______
Sleep Disturbances yes no ______
Hallucinations yes no ______
Paranoia yes no ______
Poor Concentration yes no ______
Alcohol/Substance Abuse yes no ______
Frequent Body Complaints ( e.g., headaches) yes no ______
Eating Disorder yes no ______
Body Image Problems yes no ______
Repetitive Thoughts (e.g., Obsessions) yes no ______
Repetitive Behaviors (e.g., counting ) yes no ______
Poor Impulse Control (e.g., ↑ spending) yes no ______
Self Mutilation yes no ______
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Sexual Abuse yes no ______
Physical Abuse yes no ______
Emotional Abuse yes no ______
Have you experienced in the past: Rating Scale 1-10 (10 =worst)
Only rate the areas to which you said “yes”
Depressed Mood or Sadness yes no ______
Irritability/Anger yes no ______
Mood Swings yes no ______
Rapid Speech yes no ______
Racing Thoughts yes no ______
Anxiety yes no ______
Constant Worry yes no ______
Panic Attacks yes no ______
Phobias yes no ______
Sleep Disturbances yes no ______
Hallucinations yes no ______
Paranoia yes no ______
Poor Concentration yes no ______
Alcohol/Substance Abuse yes no ______
Frequent Body Complaints ( e.g., headaches) yes no ______
Eating Disorder yes no ______
Body Image Problems yes no ______
Repetitive Thoughts (e.g., Obsessions) yes no ______
Repetitive Behaviors (e.g., counting ) yes no ______
Poor Impulse Control (e.g., ↑ spending) yes no ______
Self Mutilation yes no ______
Sexual Abuse yes no ______
Physical Abuse yes no ______
Emotional Abuse yes no ______
Occupational and Educational Information:
Are you employed? □ No □ Yes
If yes, who is your current employer/position? __________________________________
If yes, are you happy at your current position? __________________________________
Please list any work-related stressors, if any: ___________________________________
Do you have financial concerns? □ No □ Yes
If yes, please explain: ______________________________________________________
Are you currently in the military? □ No □ Yes Previously? □ No □ Yes
Highest level of education:__________________________________________________
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FAMILY MENTAL HEALTH HISTORY:
Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following?
(circle any that apply and list family member, e.g., Sibling, Parent, Uncle, etc.):
Difficulty Family Member(s)
Depression yes/no ___________________________
Bipolar Disorder yes/no ___________________________
Anxiety Disorders yes/no ___________________________
Panic Attacks yes/no ___________________________
Schizophrenia yes/no ___________________________
Alcohol/Substance Abuse yes/no ___________________________
Eating Disorders yes/no ___________________________
Learning Disabilities yes/no ___________________________
Trauma History yes/no ___________________________
Suicide Attempts yes/no ___________________________
Psychiatric Hospitalizations yes/no ___________________________
Other Information:
What role, if any, do religion and/or spirituality play in your life?
What do you consider to be your strengths? What do you like most about yourself?
What are effective coping strategies you use when stressed?
Is there anything that I did not ask about here that would be important for me to know about you?
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