Action Relational Therapy
INTAKE FORM |
Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.
Please fill out this form to confirm your first session. |
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| First Name:
Middle Name:
Last Name:
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| Name of parent/guardian (if under 18 years): |
| First Name:
Middle Name:
Last Name:
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| Birth Date:
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Gender:
Male
Female |
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| Marital Status: |
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Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed |
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| Please list any children and age: |
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| Address:
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| City:
State:
Zip Code:
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| Home Phone:
May we leave a message?
Yes
No |
| Mobile Phone:
May we leave a message?
Yes
No |
| Work Phone:
May we leave a message?
Yes
No |
| e-Mail:
May we leave a message?
Yes
No |
| *please note: email correspondence is not considered to be a confidential medium of communication. |
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| Referred by (if any):
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| 1. Have you previously received any type of mental health services (psychotherapy, psychiatric, services, etc.)? |
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No |
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Yes, previous therapist/practitioner:
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| 2. Are you currently taking any prescription medication? |
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No |
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Yes |
| 2.1 Please list: |
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| 3. Have you ever been prescribed psychiatric medication? |
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No |
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Yes |
| 3.1 Please list and provide dates: |
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| GENERAL HEALTH AND MENTAL HEALTH INFORMATION |
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| 4. How would you rate your current physical health? |
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Poor
Unsatisfactory
Satisfactory
Good
Very Good |
| 4.1 Please list any specific health problems you are currently experiencing: |
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| 5. How would you rate your current sleeping habits? |
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Poor
Unsatisfactory
Satisfactory
Good
Very Good |
| 5.1 Please list any specific sleep problems you are currently experiencing: |
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| 6. How many times per week do you generally exercise?
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| 6.1 What types of exercises do you participate in: |
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| 7. Please list any difficulties you experience with your appetite or eating patterns: |
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| 8. Are you currently experiencing overwhelming, grief or depression? |
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No |
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Yes
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| 8.1 For approximately how long? |
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| 9. Are you experiencing anxiety, panic attacks or have any phobias? |
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No |
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Yes |
| 9.1 When did you begin experiencing this? |
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| 10. Are you currently experiencing any chronic pain? |
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No |
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Yes |
| 10.1 Please describe: |
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| 11. Do you drink alcohol more than once a week? |
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No |
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Yes |
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| 12. How often do you engage in recreational drug use? |
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Daily
Weekly
Monthly
Infrequently
Never
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| 13. Are you currently in a romantic relationship? |
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No |
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Yes |
| 13.1 For how long? |
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| 13.2 On a scale of 1-10, how would you rate your relationship?
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| 14. What significant life changes or stressful events have you experienced recently? |
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| FAMILY MENTAL HEALTH HISTORY [OPTIONAL] |
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| In the section below identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (father, grandmother, uncle, etc.). |
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| ADDITIONAL INFORMATION: |
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| 15. Are you currently employed? |
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No |
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Yes
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| 15.1 If yes, what is your currently employment situation? |
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| 15.2 Do you enjoy your work? Is there anything stressful about your current work? |
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| 16. Do you consider yourself to be spiritual or religious? |
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No |
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Yes |
| 16.1 Please, describe your faith or belief: |
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| 17. What do you consider to be some of your strengths? |
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| 18. What do you consider to be some of your weaknesses? |
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| 19. What would you like to accomplish out of your time in therapy? |
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| Digital Signature |
(By clicking the following button, you are digitally signing
that you have read the terms & conditions and agree
to a
accept such terms and conditions on the intake form.) |
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