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Client Intake Questionnaire Form

The Client Intake Questionnaire is a confidential document designed to gather personal, emergency, employment, education, family, lifestyle, medical, and referral information from clients seeking counseling. It includes sections for presenting concerns and goals for counseling, as well as a signature section for both the client and counselor. All information is kept private and is only accessible to the assigned counselor.

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Howard Zeal Bowa
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© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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44 views4 pages

Client Intake Questionnaire Form

The Client Intake Questionnaire is a confidential document designed to gather personal, emergency, employment, education, family, lifestyle, medical, and referral information from clients seeking counseling. It includes sections for presenting concerns and goals for counseling, as well as a signature section for both the client and counselor. All information is kept private and is only accessible to the assigned counselor.

Uploaded by

Howard Zeal Bowa
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Client Intake Questionnaire

Disclaimer: The information provided in this document will not be shared with any third parties
and will only be accessible to your assigned counsellor.

Personal Information
1. Full Name:
2. Date of Birth:
3. Gender:
4. Physical Address:
5. Phone Number:
6. Email Address:
7. Preferred Method of Contact (phone, email, etc.):

Emergency Contact
1. Full Name:
2. Relationship:
3. Phone Number:

Employment and Education


1. Occupation:
2. Employer:
3. Highest Level of Education:
4. Current School/College (if applicable):

Family and Social Information


1. Marital/Relationship Status:
2. Do you have children?
● Yes
● No
● If yes, please list their ages:
3. Describe your current living situation:
4. Do you have a support system (friends, family, community)?
● Yes
● No
● If yes, please describe:

Lifestyle and Self-Care


1. How do you spend your leisure time?
2. Do you engage in regular physical activity?
● Yes
● No
● If yes, please describe:
3. How would you rate your quality of sleep?
● Excellent
● Good
● Fair
● Poor

Medical and Mental Health History


1. Do you have any current medical conditions?
● Yes
● No
● If yes, please specify:
2. Are you currently taking any medications?
● Yes
● No
● If yes, please list the medications and their purposes:
3. Have you ever been diagnosed with a mental health condition?
● Yes
● No
● If yes, please specify:
4. Have you ever been hospitalized for mental health reasons?
● Yes
● No
● If yes, please provide details:
5. Do you use tobacco?
● Yes
● No
● If yes, how often and how much:
6. Do you consume alcohol?
● Yes
● No
● If yes, how often and how much:
7. Do you use recreational drugs?
● Yes
● No
● If yes, please specify and provide frequency:

Referral Information
1. How did you hear about our services?
● Friend/Family
● Doctor/Healthcare Provider
● Internet/Search Engine
● Insurance Provider
● Other (please specify):

Presenting Concerns
1. What brings you to counselling at this time? Please describe your main concerns:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2. How long have you been experiencing these concerns?
3. Have you previously sought counselling or other mental health services?
● Yes
● No
● If yes, when and with whom:

Additional Information
1. What are your goals for counselling?
2. Is there any other information you feel is important for your counselor to know?

Signature:
By signing below, you confirm that the information provided is accurate to the best of your
knowledge.

Client Signature: ____________________________________


Date: _______________________________________________

Counsellor Name: ______________________________________


Counsellor Signature: ___________________________________
Date: _______________________________________________

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