Client Intake Form | Serene Therapy

First name

Last name

Date of Birth

Day

Month

Year

Age

Phone

Email

Please list the problem(s) for which you are seeking help.

What qualities or approach do you prefer in a therapist? (Select all that apply. If any.)

Gender

Do you currently feel that you don't want to live?

Yes

No

How often do you have these thoughts?

When was the last time you had thoughts of dying?

Do you feel hopeless and/or worthless?

Yes

No

Have you ever tried to kill or harm yourself before?

Yes

No

Do you exercise regularly?

Yes

No

How many times do you exercise?

How many caffeinated beverages do you drink in a day?

Where did you grow up?

Do you have a history of being abused emotionally, sexually, or physically or by neglect? If yes, please describe when, where, and by whom.

Highest grade completed?

Do you have any children

Yes

No

Have you ever been arrested?

Yes

No

Emergency Contact

Phone number of contact

Choose date and time of the session

Day

Month

Year

Time

HoursMinutes

Signature

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Signature of Consent of parent/legal guardian if not 18

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