CLIENT INTAKE FORM

Please answer the following questions to the best of your abilities. These questions are to help the therapist with the therapy process. This information is held to the same standards of confidentiality as our therapy.

Date

First name

Last name

Cell Phone

Home Phone

Work Phone

Address

Birthday

Marital Status

Emergency Contact Name & Number

Referred by?

If yes, please share the reason for changing:

If yes, please list:

If yes, please list dates and locations:

Please provide the name, address and telephone number for your primary care physician:

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, thyroid dysfunction, etc.):

Please list any medications you're taking for physical/medical issues:

Please list other sleep conditions of challenges:

Please explain your alcohol consumption. How many drinks per week?

How often do you engage in recreational drug use? Please list your substances of choice.

Are you currently in a romantic relationship? If yes, for how long?

In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?

Client Intake Form

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