Intake Questionnaire
C O N F I D E N T I A L
In order to better serve your needs, it is helpful for our therapists to have information about you and your concerns as you come to your first appointment. Please fill out as much information as possible and bring this to your first appointment.
Person’s Name: DOB:
Address:
Insurance: Age:
Referral Source: How did you hear about Summit Community Counseling?
Chief Complaint (client’s own words): Why are you seeking help? What brings you to therapy?
Psychiatric/Treatment History: Have you had treatment before? If so, when and with whom? What did you find helpful and what was not helpful? Have you been hospitalized for mental health issues?
History of Presenting Problem: How long have you had these issues? When did you first have concerns or feel like you needed help?
Social History/Family History/Placement History:What was the make up of your family of origin, for ex., do you have siblings, were your parents married, are they living? Are you currently married? Do you have children? Give a brief history of your family and where you have lived.
Trauma History/Significant Life Events: Have you been a victim of abuse? Have you had significant traumatic events occur which you feel affect you?
Drug/Alcohol/Nicotine Usage: Do you use illegal drugs, alcohol, or nicotine? If so, how much and how often.
Daily Living Skills/Independent Living Skills/Leisure skills: Are you able to complete your daily life chores on your own? How does your current mental health concern affect your ability to complete personal hygiene chores, chores of daily living such as keeping your house clean, shopping, bill paying, and maintaining a household? What do you do for fun or relaxation?
Education/Employment History: Did you receive special services in school? Did you graduate from high school? Have you attended any college or further training? What is your employment history?
Current Social Supports/Peer Relationships: Who do you have to support you emotionally? Do you have friends, neighbors, family or other social organizations to offer support to you?
Medical Issues: Do you have any medical issues? Have you had any head injuries or concussions? Please list current medications.
Strengths: What are your strengths? What are good things about you?
Goals for Therapy/What your therapist needs to know about you: What are your goals for therapy? What would be important for your therapist to know about you in order to help you the most.
Thank you for your time! If you have any questions or problems, please contact our office manager, Ben Angell or our executive director, Karen Malm at the number below.
5689 S Redwood Road Ste 27A P 1 (801) 266 - 2485
Taylorsville, UT 84123F 1 (866) 644 - 9206