CLIENT INTAKE FORM
Disclaimer: Thank you for prioritizing your mental health and allowing me to help you. This form
is used to collect information about new clients and for internal purposes only. The information
you provide is confidential and will be treated accordingly.
Today’s Date: ______________
24/Dec/2025
CLIENT INFORMATION
Name: ______________________
Ashhar Husain Birth date: _______________
24/03/2007 Current age: ______
19
Address: _____________________________
Sir syed nagar aligrah City: _______________
Aligrah Zip: _____________
2020002
Cellphone: _______________
7007244966 Is it okay to: ☐ Phone? ☐ Leave a message? ☐ Whatsapp?
Secondary phone: _______________
6306807871 Is it okay to: ☐ Phone? ☐ Leave a message? ☐ Text?
Email: ___________________________
ashharhusain8283@[Link] (Please be aware that emails may not be confidential)
-Is it okay to email you regarding your appointment? ☐ Yes ☐ No
Preferred method of contact: ☐ Cellphone ☐ Secondary phone ☐ Email ☐ Whatsapp
☐ Other (specify) ___________________________
Emergency contact name: _____________________
Abid Haider Relationship to you: _______________
Friend
Phone: _______________
79-85102007 Address: _____________________________
Sajjad bagh lucknow
DEMOGRAPHIC INFORMATION
Gender: ☐ Female ☐ Male ☐ Transgender ☐ Other (specify) ____________________
Ethnicity: _____________________
Indian ☐ Prefer not to answer
Sexual orientation: ☐ Bisexual ☐ Heterosexual ☐ Lesbian/gay ☐ Questioning
☐ Other (specify) ____________________
Religious/cultural identity: _____________________
Muslim ☐ Prefer not to answer
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Relationship status: ☐ Single ☐ Partnered ☐ Married ☐ Separated ☐ Divorced ☐ Widowed
☐ Other (specify) ____________________
-If applicable, please list your current or former partner or spouse’s age and occupation:
_____________________________________________________________
Student
-If applicable, how long have you been/were you in this relationship? ____________________
5 years
Check the highest degree you’ve earned: ☐ GED ☐ High school ☐ Associate’s degree
☐ Bachelor’s degree ☐ Master’s degree ☐ Doctoral degree
-Current/former schools: ________________________________________________________
-Field(s) of study: ______________________________________________________________
Science
Are you currently employed? ☐ Yes ☐ No
-If yes, list your current occupation and employer. If no, list your former occupation and
employer: ____________________________________________________________________
Are you a veteran? ☐ Yes ☐ No
-If yes, what branch of military? __________________ Time of service: ___________________
Who referred you to the clinic/therapist?
☐ Self ☐ Friend ☐ Family member ☐ School ☐ Hospital ☐ Clergy/religious leader
☐ Medical provider ☐ Mental health provider
-If referred by a physician or mental health provider, please provide their name and contact
information: _________________________________________________________
Fauzaia +91 731-0739552
HEALTH HISTORY
Primary care physician name: ________________________
Dr Arfeen Phone: ___________________
Address: ________________________________________
Sir syed nagar aligrah
Psychiatrist name: ________________________
Fauzaia Phone: ___________________
+91 731-0739552
Address: ________________________________________
Sir syed nagar aligarh
Other health professional name: _______________________
- Phone: __________________
Address: ________________________________________
When was your last physical exam? ____________
1 month back
How is your physical health? ☐ Poor ☐ Unsatisfactory ☐ Satisfactory ☐ Good ☐ Excellent
Have you had any serious accidents or injuries? ☐ Yes ☐ No
-If yes, please describe: _________________________________________________________
No
Please describe any medical issues or hospitalizations you’ve had:
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Please list any other persistent physical symptoms or health concerns:
I was suffering form psychological sexual health issues
Do you regularly take any prescribed medications, over-the-counter drugs, supplements,
or alternative remedies to treat a medical condition? ☐ Yes ☐ No
-Psychiatric medications? ☐ Yes ☐ No
-If yes, please list any medications you are currently taking, the condition for which the
medication is taken, and the prescribing physician (if applicable):
Are you having problems with your sleeping habits? ☐ No problems ☐ Sleeping too much
☐ Sleeping too little ☐ Poor quality of sleep ☐ Disturbing dreams ☐ Other _________________
How many times a week do you exercise? ☐ One or less ☐ Two to four ☐ Five or more
-For about how long do you exercise at a time? _________________
Are you currently having difficulty with your appetite or eating habits? ☐ No difficulty
☐ Eating less ☐ Eating more ☐ Bingeing ☐ Restricting ☐ Significant weight gain or loss
-Please describe the nature of your eating habits or weight change:
Im healthy with good bmi
Do you have any problems or worries about your sexual functioning?
☐ No concerns ☐ Lack of desire ☐ Performance problem ☐ Sexual impulsiveness
☐ Difficulty maintaining arousal ☐ Worried about STDs ☐ Other _________________
Psychological issues
Have you received counseling services in the past? ☐ Yes ☐ No
-If yes, please explain, including when, with whom, and whether you found it helpful:
I was taking it from my family friend she is a psychologist herself
Are you currently receiving psychiatric services, professional counseling, or
psychotherapy elsewhere? ☐ Yes ☐ No
-If yes, please specify the mental health provider’s name and phone number:
____________________________________________________________________________
Have you ever been assessed for psychological or learning issues by a therapist, school
counselor, or other provider? ☐ Yes ☐ No
-If yes, please explain, including when and by whom, and the findings/diagnosis:
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Have you been prescribed psychiatric medication in the past? ☐ Yes ☐ No
-If yes, please list what medications, the dosage, and when taken:
Were the medications helpful? ☐ Yes ☐ No
Have you ever been hospitalized for psychiatric reasons? ☐ Yes ☐ No
-If yes, please specify the reasons for past hospitalization:
☐ Psychological problems ☐ Suicidal thoughts/attempt ☐ Dangerousness to others
☐ Drugs/alcohol ☐ Other ________________________________
Was the hospitalization helpful? ☐ Yes ☐ No
FAMILY AND SOCIAL INFORMATION
Please list the members of your family to whom you are close (not including any
children), and specify their name, relationship to you, living or deceased, age (or age at
the time of death), and occupation:
Do you have children? ☐ Yes ☐ No
-If yes, please list their names, living or deceased, age (or age at the time of death), and gender
(indicate if they are step, foster, or adopted):
Do you have full custody of your children? ☐ Yes ☐ No
-If no, describe the custody arrangement: ___________________________________________
Any family history of mental illness, substance abuse, or learning difficulties?
☐ Yes ☐ No
-If yes, please provide a brief explanation:
Besides family members, approximately how many people can you count on right now
for friendship and emotional support?
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PRESENTING CONCERNS
Briefly describe why you’re seeking therapy:
Is there any additional information about you (e.g., current difficulties, special
circumstances, or challenges within your family, relationships, educational or work
environment) that would be helpful for us to know?
Approximately how long have these concerns been bothering you?
☐ Couple days ☐ A week ☐ A month ☐ Many months ☐ A year ☐ Many years ☐ Most of my life
How much do these concerns interfere with your:
Daily routine: Very little - ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 - Severely
Emotional well-being: Very little - ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 - Severely
Relationships/activities:
Very little - ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 - Severely
Work/school:
Very little - ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 - Severely
ACKNOWLEDGMENT
Signature: ______________________ Date: _______________
24/Nov/25
Print Name: ______________________
Ashhar
Guardian Signature (if required) ____________________ Date: _______________
Print Name: ______________________
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