Intake Form
Uploaded by
NIcole Anne SoriaIntake Form
Uploaded by
NIcole Anne SoriaUnit 4, Aglipay Building- Extension, Bontoc, Mountain Province | 09279617717| ampsych.services18@gmail.
com
Intake
CLIENT’S INFORMATION
Name: ______________________________________________ Age:__________ Gender: _________
Address: ________________________________________________________
Contact Number: ___________________________ Email: ___________________________
Emergency Contact: ______________________________________________
Relationship to Client: ___________________________
Emergency Contact Number: ___________________________
Reason for seeking psychological
1. What are the reasons for your visit today?
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________
2. Are any of the following conditions a problem to the client at this time? (Check the ones
that apply)
Thoughts of Anxiety Sexual orientation
suicide Panic attacks Gender identity
Plans to harm self Chronic fear issues
Thoughts of Irrational fears Relationship with
harming someone Problems due to parents
else abuse/ trauma Relationship with
Self-injury Obsessions/ children
Depression compulsions Conflicts at work
Grief Behavioral Problems in school
Stress problems Substance abuse
Loneliness ADHD Others:____________
Guilt feelings Anger ___________________
Loss of hope management ______
Loss of meaning in Problems with a
life relationship
Problems with partner
sleep Sexual problems
3. When does the symptom become apparent?
___________________________________________________________________________________________
_____
PERSONAL HISTORY
The information in this form is strictly confidential. Please fill out the form as completely as possible. 1
These are personal history questions. To save time in your first session, this form collects
background information. Please skip questions that don't apply to your case. Your counselor will
have a better understanding of your issue if you offer additional information. You can ask
1. Have you ever been to counseling or therapy before? Yes No
If yes, please provide a brief history of your past therapy experiences:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________
The information in this form is strictly confidential. Please fill out the form as completely as possible. 2
2. Have you ever been diagnosed with a mental health disorder? Yes No
If yes, please provide a brief description of the diagnosis:
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________
3. Have you ever been hospitalized for psychiatric reasons? Yes No
If yes, please provide a brief description of the hospitalization:
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________
4. Are you currently taking any medications for mental health issues? Yes No
If yes, please provide a list of the medications:
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________
5. What do you hope to gain from therapy?
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________
___________________________________________________________________________________________
______________
6. Is there any additional information you feel would be helpful for the therapist to know?
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________
Acknowledgement
Please sign and date this document attesting that the information you have written on this
form is accurate to the best of your knowledge.
__________________________________ _________________________
Signature Date
(Client/ Parent/ Guardian)
The information in this form is strictly confidential. Please fill out the form as completely as possible. 3
