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Client Intake Form

Please take a few minutes to answer the questions below. All information will be kept confidential. 

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I look forward to meeting you! 

Ok to leave voicemail?
Yes
No
Employment Status
Full time
Part time
Self employed
Unemployed
Caregiver
Student

Structural Conditions

Please indicate which conditions you have experienced or diagnosed with in the past 5 years or more.

Multi choice

Mental / Emotional Conditions

Please indicate which conditions you have experienced or diagnosed with in the past 5 years or more.

Multi choice

Physiological Conditions

Please indicate which conditions you have experienced or diagnosed with in the past 5 years or more.

Multi choice

CNS Conditions

Please indicate which conditions you have experienced or diagnosed with in the past 5 years or more.

Multi choice

Other Symptoms

Please indicate which other symptoms you have experienced or diagnosed with in the past 5 years or more.

Multi choice

Adverse Childhood Experiences

Answer the following questions "yes, no, not sure". Then elaborate in the space below on anything you feel is important for me to know.

Have you, or your ancestors experienced significant historical, racial, or cultural traumas, like displacement, war, or even experiences related to genocide? For instance, Holocaust survivors?
Yes
No
Not sure
Does your family have a history of violence, neglect, domestic abuse, substance use disorder, poverty, mental illness, racial, or sexual trauma?
Yes
No
Not sure
Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, humiliate you, or act in a way that made you afraid that you might be physically hurt?
Yes
No
Not sure
Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you or another family member, or ever hit you so hard that you had marks or were injured?
Yes
No
Not sure
Did an adult or person at least 5 years older than you ever… Cross any boundaries in a sexual way?
Yes
No
Not sure
Did you often or very often feel that … No one in your family loved you, thought you were important or special, or your family didn’t look out for each other, feel close to each other, or support each other?
Yes
No
Not sure
Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you, or your parents were too drunk, high, or absent to take care of you or take you to the doctor if you needed it?
Yes
No
Not sure
Have you lost a parent or other primary caregiver through divorce, abandonment, death, or other reason?
Yes
No
Not sure
Has any immediate member of your household ever gone to jail or prison?
Yes
No
Not sure

Surgeries / Other Medical Interventions

What Else Have You Tried?

Social Characteristics

Would your close friends/family describe you as a perfectionist?
Yes
No
Not sure
Would your close friends/family describe you as a problem solver?
Yes
No
Not sure
Would your close friends/family describe you as being rigid?
Yes
No
Not sure

Preferences and beliefs

Indicate which therapeutic options appeal to you.

Thank you! On your first appointment, we will review this information and discuss any other pertinent information.

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