IN  TAKE  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 and bring it to your first session.

Name: ________________________________________________________________________

               (Last)                                                (First)                                                 (Middle Initial)

Name of parent/guardian (if under 18 years): __________________________________________

                                                                         (Last)                    (First)                    (Middle Initial)

Birth Date: ______ /______ /______        Age: ________         Gender: ___ Male   ___Female

Marital Status:

___ Never Married ___ Domestic Partnership ___ Married ? Separated ___ Divorced ___ Widowed

Please list any children/age: ________________________________________________________

Address: _______________________________________________________________________

                                                                   (Street and Number)

_______________________________________________________________________________

 (City)                                                                    (State)                                                            (Zip)

Home Phone: (___) ______________      May we leave a message?   ___Yes   ___No

Cell/Other Phone: (___) ______________      May we leave a message?   ___Yes   ___No

E-mail: _________________________________________      May we email you?   ___Yes   ___No

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Referred by (if any): _______________________________________________________________

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?  ___No  ___Yes, previous therapist/practitioner: ______________________________________

Are you currently taking any prescription medication?  ___No  ___Yes

Please list: ________________________________________________________________________

_________________________________________________________________________________

Have you ever been prescribed psychiatric medication?  ___No  ___Yes

Please list and provide dates: _________________________________________________________

_________________________________________________________________________________

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

1. How would you rate your current physical health? (Please circle)

Poor            Unsatisfactory            Satisfactory            Good            Very good

Please list any specific health problems you are currently experiencing:

_________________________________________________________________________________

2. How would you rate your current sleeping habits? (Please circle)

Poor            Unsatisfactory            Satisfactory            Good            Very good

Please list any specific sleep problems you are currently experiencing:

_________________________________________________________________________________

3. How many times per week do you generally exercise? ____________________________________

What types of exercise to you participate in: ______________________________________________

4. Please list any difficulties you experience with your appetite or eating patterns.

_________________________________________________________________________________

5. Are you currently experiencing overwhelming sadness, grief or depression?  ___No  ___Yes

If yes, for approximately how long? _____________________________________________________

6. Are you currently experiencing anxiety, panic attacks or have any phobias?  ___No  ___Yes

If yes, when did you begin experiencing this? _____________________________________________

7. Are you currently experiencing any chronic pain?  ___No  ___Yes

If yes, please describe? ______________________________________________________________

8. Do you drink alcohol more than once a week?  ___No  ___Yes

9. How often do you engage recreational drug use?

___Daily        ___Weekly        ___Monthly        ___Infrequently        ___Never

10. Are you currently in a romantic relationship?  ___No  ___Yes

If yes, for how long? ________________________________________________________________

On a scale of 1-10, how would you rate your relationship? __________________________________

11. What significant life changes or stressful events have you experienced recently?

_________________________________________________________________________________
FAMILY MENTAL HEALTH HISTORY:

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.).

                                                                                                                 List Family Member

Alcohol/Substance Abuse ___No  ___Yes                        __________________________________

Anxiety ___No  ___Yes                                                     __________________________________

Depression  ___No  ___Yes                                              __________________________________

Domestic Violence ___No  ___Yes                                   __________________________________

Eating Disorders ___No  ___Yes                                       __________________________________

Obesity ___No  ___Yes                                                     __________________________________

Obsessive Compulsive Behavior ___No   ___Yes               __________________________________

Schizophrenia ___No  ___Yes                                          __________________________________

Suicide Attempts ___No  ___Yes                                      __________________________________

ADDITIONAL INFORMATION:

1. Are you currently employed? ___No  ___Yes

If yes, what is your current employment situation?

_________________________________________________________________________________

Do you enjoy your work? Is there anything stressful about your current work?

_________________________________________________________________________________

_________________________________________________________________________________

2. Do you consider yourself to be spiritual or religious? ___No  ___Yes

If yes, describe your faith or belief:

_________________________________________________________________________________

3. What do you consider to be some of your strengths?

_________________________________________________________________________________

_________________________________________________________________________________

4. What do you consider to be some of your weakness?

_________________________________________________________________________________

_________________________________________________________________________________

5. What would you like to accomplish out of your time in therapy?

_________________________________________________________________________________

_________________________________________________________________________________