Adult Psychotherapy Intake Form

First and Last Name
Date of birth
Referred by
What is the main reason you're seeking help?
How long has this been an issue?
What are your goals for therapy
Do you currently have any medical problems or psychiatric problems?
Have you previously seen a therapist? If so, what year? Who did you see and for what reason? About how many meetings did you have? Was the experience helpful or not?
Are you currently seeing a counselor or a psychiatrist? If so, please list the name(s).
Have you ever been hospitalized for medical or mental illness? If so, list when, where and reason.
Please list current prescription medications with dosage (psychiatric and general health):
Do you drink or use recreational drugs? If so, what kind and how often?
Do you or anyone close to you consider your use to be a problem?
Do you have any concerns about your overall health?
Do you or any of your extended family members have a history of any mental health related issues?
Are you currently married/partnered/divorced/single?
Do you have any concerns about your current marital or relationship status?
Please describe your social relationships. Do you have friends? Extended family? Go out for fun? Socialize? Whom can you turn to for emotional and other forms of support?
Are your currently employed? Please describe your current work or academic situation?
What are some of your interests and activities?
Do you consider yourself spiritual or religious?
Have you experienced any unusually severe stresses during the last year? Please describe.
Is there any information you would like to add?
Emergency Name and Contact
Are you currently, or have you experienced suicidal thoughts in the past?
Have you ever attempted suicide? If so, number of attempts.