Client Intake and Information Form

Intake Form Page _____ of 6

Ashley Davis, MA, LPC

Psychotherapist

777 29th Street, Suite 401

Boulder, Colorado 80303

(303) 919-4149

Client Intake and Information Form

Personal Information

Client Name:______Date: ______

Age: ______Date of Birth: ______Social Security # ______

Phone: (Home):______(Mobile/Work):______

Where may I leave messages? ______

Email Address (if applicable): ______

Address: ______City: ______State: ______Zip: ______

May I have permission to mail to this address? Yes______No______

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Spouse/Partner: ______Date of Birth: ______

Social Security # ______Employer:______

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*Responsible Party (if other than above):______

Social Security # ______Employer:______

Phone: Home:______Mobile/Work:______

Where may I leave messages? ______

Address: ______

City: ______State: ______Zip: ______

______

Referred to Therapy By: ______

Emergency Contact:

Name:______Phone:______Relationship:______

Others Living in the Home: (including children)

NameDate of BirthAgeRelationship

1. ______

2. ______

3. ______

Please Describe your Current Living Situation:______

______

Presenting Problem

Reasons for seeking therapy at this time: ______

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When did your concerns first arise? ______

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What makes things better or worse? ______

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Treatment Goals

1. ______

______

2. ______

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3. ______

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Relationship Status Information:

Marital Status: (single, married, divorced, remarried, separated, engaged, living together, etc.) ______

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Does your spouse/partner support your desire to participate in psychotherapy? Yes_____ No_____

If so, please explain: ______

If you are no longer married or in a committed relationship, when did that change and why?

______

Employment HistoryAnd Education Volunteer Employment

_____ Employed Full Time_____ None

_____ Employed Part Time_____ 1-10 hours per week

_____ Homemaker-Not otherwise employed_____ 10 plus hours per week

_____ Other: ______

Current or Most Recent Employer: ______

How long have you worked in this position? ______

Do you enjoy what you do most of the time? ______

Education: ______

What is the highest grade that you completed? ______

Academic strengths/limitations/frustration/current interests:______

______

Medical History

Date of Last Physical: ______

Doctor’s Name ______Doctor’s Number (_____)______

Doctor’s Address ______

City______State______Zip______

Past or Current Medical Problems:______

______

Are you taking any prescribed medications? Yes______No______If so, please list:______

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History of Alcohol/Substance abuse (past or present): Yes______No______If yes, please explain: ______

______

Please indicate any substance that you use:

SubstanceCurrent use per dayCurrent use per week

Caffeine______

Nicotine______

Beer______

Wine______

Liquor______

Marijuana______

Cocaine______

Other Drugs:

______

Have you ever used any substance more frequently than currently used?

If yes, please describe: ______

______

Has the client ever participated in treatment for drug or substance abuse problems?Yes______No______

If yes, please explain: ______

______

History of Physical/Sexual Abuse and/or Neglect? Yes______No______If yes, please explain: ______

______

Do you have a history of suicide attempts? Yes______No______If yes, when, how and what happened? ______

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Do you have any feelings of wanting to hurt yourself? Yes______No______If so, please explain: ______

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Do you have plans of wanting to harm others? Yes______No______If so, please explain:______

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Have you ever been hospitalized for mental health concerns? Yes______No______If yes, please indicated number of times, when, how and what happened: ______

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Have you ever been involved in the court system? Yes______No______If so, please explain: ______

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Please describe your overall mood in the last 2-6 months: ______

______

Please describe for the last 6 months:

Sleep (do you sleep through the night, troubles falling asleep, etc.): ______

______

Appetite (increase/decrease): ______

______

Weight (gain/loss):______

Current Symptoms(Check all that apply)

_____ Anxiety_____ Sleep Concerns_____ Depression

_____ Appetite_____ Manic-Like Symptoms_____ Weight Gain/Loss

_____ Grief/Loss_____ Memory Concerns_____ Irritability

_____ Feelings of Apathy_____ Cognitive Problems_____ Hallucinations

_____ Financial Problems_____ Delusions_____ Educational Concerns

_____ Irritability_____ Support System Concerns_____ Feelings of Hopelessness ______Other______

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Family Medical History

Does anyone in your family have a history of mental health issues? Yes______No______If so, please explain:______

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Does anyone in your family have a history of drug/alcohol abuse? Yes______No______If so, please explain: ______

______

Has anyone in your family attempted suicide? Yes______No______If so, please explain:______

______

Does anyone in your family have a history of severe trauma? Yes______No______If so, please explain:______

______

Birth History:

Please describe your birth history (e.g., weight, full-term, c-section): ______

______

Family History

How would you describe your family growing up? ______

______

Were your parents separated or divorced? ______

______

What was your birth order amongst your siblings?______

______

To whom in your family did you feel closest growing up and why?______

In your opinion, did any of your family members or immediate relatives have a problem controlling anger or with violent and/or abusive behavior? Yes______No______If so, please explain: ______

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Describe any major losses and /or deaths you have experienced: ______

______

Describe any major traumas/key events you have experienced (including court/custody cases): ______

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Describe your feelings and impressions of your childhood: ______

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General Information:

Do you have any spiritual or religious affiliation: Yes______No______If so, please explain: ____

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Personal Interests and Hobbies: ______

______

Who are the most important people in your life right now? ______

______

What are your strengths/qualities you like about yourself? ______

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What childhood events/relationships/experience do you feel contributed to your strengths today?__

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Previous Therapy? Yes______No______If so, when, how long and outcome: ______

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Is there anything else you would like to tell me about you. ______

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Thank you for taking the time to fill out this form. It is helpful information as we begin to work together. This information will be kept confidential.