4500 Park Glen Road Suite 155

CYNTHIA J. HAAKANA, Ph.D., L.P.

St. Louis Park, Minnesota 55416-4888

952-928-0618

952-928-9774 (fax)

INTAKE FORM

TODAY’S DATE: ______FILE #: ______DX: ______

CLIENT NAME: ______DOB: ______Parent Name (if minor): ______

Home Phone #: ______Work Phone #:______Cell Phone #:______

Preferred phone # is Home, Work, or Cell? Therapist can contact me at home or work and/or leave a message. YES NO

Address, city, state,zip:______

Referred By: ______May I say thank you for referring you to me? YES NO

Employer: ______Job Title ______

Education: ______

FAMILY INFORMATION: Relationship Status (circle): SINGLE MARRIED DIVORCED LIVING TOGETHER

Partner/Significant other’sname:______

Number of years in relationship/married: ______Previous Marriages/Divorces? ______

Dates of marriages and/or divorces______

Children (Names and ages):

______

Describe your relationship with your children: ______

______

FAMILY OF ORIGIN:

Father’s Name: ______Age: ______Living? ______Where? ______

Marital Status: ______Education: ______Occupation: ______

Mother’s Name: ______Age:______Living? ______Where? ______

Marital Status: ______Education: ______Occupation: ______

Describe relationship with your parents: ______

______

List Siblings (Oldest to youngest and include yourself):

Name: ______Age: ______Living? ______Where?: ______Occupation: ______

Name: ______Age: ______Living? ______Where?: ______Occupation:______

Describe relationships with siblings: ______

______

Has anyone in your family had a serious mental health problem? ______

______

(Complete side two)

CHEMICAL USE:

Do you use: Alcohol ______Tobacco ______Caffeine ______

Do you think you have a current problem with drugs/alcohol, etc.? YES: _____ NO: _____ MAYBE: _____

Have you ever felt that you ought to Cut down on your drinking or drug use? YES___ NO___

Have people Annoyed you by criticizing your drinking or drug use? YES___NO___

Have you ever felt bad or Guilty about your drinking or drug usage? YES___ NO ___

Have you ever had a to drink or use drugs/alcohol first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover or just get the day started? YES___ NO___

What medications are you currently using? ______

CURRENT HEALTH:

Describe your general health: ______

Describe concerns and/or changes in:

Sleeping: ______

Work Life: ______

Hobbies/Play: ______

Relationships: ______

Financial: ______

Spiritual: ______

Physical Health: ______

Sexuality: ______

Anything else: ______

What do you like about yourself? ______

What do you do for fun? ______

CURRENT CONCERNS AND/OR PROBLEMS CHECKLIST:

_____Relationship with parents _____Childhood abuse _____Grief _____Death

_____Relationship with children _____Emotional abuse _____Alcohol/chemical use _____Suicidal feelings

_____Relationship with friends _____Verbal abuse _____Compulsiveness _____Loneliness

_____Relationship with partner/ _____Sexual abuse _____Overeating _____Employment

Significant other _____Sexual acting out _____Rapid weight changes _____Finances

_____Relationship with _____Sexuality _____Eating disorders _____Overworking

Co-workers/boss _____Sexual orientation _____Anxiety _____Career/job

_____Codependency _____Sexual identity _____Depression _____Pregnancy/having children

_____Personal growth _____Spiritual/religious _____Phobias (list):______

_____Other issues: ______

PREVIOUS COUNSELING:

Have you ever had counseling? ______Date of counseling: ______Agency/counselor: ______

Problem treated: ______

Did you like your experience in counseling? ______

Was counseling successful? ______

What is your current reason for seeking therapy? ______

How long have you been experiencing this problem? ______

What have you tried so far that has helped? ______

What have you tried that has not helped? ______

Is there anything else you would like to add that may be helpful? ______

______

Client signature:

Signature:______Date:______