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CLIENT IN-TAKE FORM

Date of Birth
Day
Month
Year
What qualities or approach do you prefer in a therapist? (Select all that apply. If any.)
Gender
Symptoms you are experiencing
Do you currently feel that you don't want to live?
Yes
No
Do you feel hopeless and/or worthless?
Yes
No
Have you ever tried to kill or harm yourself before?
Yes
No
Has anyone in your family been diagnosed with or treated for:
Do you exercise regularly?
Yes
No
What best describes your family or household structure?
Nuclear Family
Extended Family
Single-Parent Family
Blended (Step) Family
Childless Family
Grandparent-Led Family
Same-Sex Family
Foster Family
Adoptive Family
Cohabiting Family
Communal/Shared Household
Child-Headed Household
Other
Are you currently:
Do you have any children
Yes
No
Have you ever been arrested?
Yes
No
Choose date and time of the session
Day
Month
Year
Time
HoursMinutes
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