Intake Form

Please complete this form to the best of your ability with the information you have available to you at this time. Do your best to answer each item as fully as you can.

Therapist*
Name*
First Last
(Legal/Chosen)
Gender*
Pronouns
Age
Birth Date*
MM
DD
YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone
Cell Phone
May I leave Voice Messages?
Email*
Emergency Contact Name
Relationship
Phone
Sexual Orientation
Ethnic/Cultural Backgroud
Religion
Relationship Status
Education Level
Occupation
Annual Income
Employer
How did you hear about us?*
Referred by
Referrer Address
May I thank this referral source for directing you to this practice?
Current Issues
Please provide a brief description of why you are seeking counseling/therapy services at this time:
Has anything happened that may have brought on/intensified the problems you are experiencing?
If yes, please explain
When (month/year) did you first begin to experience these problems?
How much is/are the problems affecting you?
In what areas do your problems impact your life?
- Lifestyle (the way you live your life)
- Activities (things you normally do or would like to do)
- Relationships (your ability to form or maintain relationships with others)
- Eating
- Shopping
- Mood
Check all that apply
Have you ever attempted suicide?
- No Answer
- Yes
- No
If yes, when?
Have you been thinking about suicide?
- No Answer
- Yes
- No
Have you been thinking about harming or killing someone else?
- No Answer
- Yes
- No
Adult Problems Checklist
Please check all that apply to you
Adult Problems Checklist
- No Answer
- Depression
- Low energy
- Low self-esteem
- Poor concentration
- Lack of interest/enjoyment in life
- Feeling hopeless
- Feeling worthless
- Feeling guilty or shameful
- Sleep changes (more/less)
- Loneliness
- Bad dreams/nightmares
- Feeling Ignored or abandoned
- Appetite changes (more/less)
- Mood swings
- Thoughts of hurting self
- Thoughts of hurting others
- Isolating from others/social withdrawal
- Feelings of sadness/loss
- Weight problems
- Stress
- Anxiety/tension/worry
- Panic attacks
- Heart racing
- Chest pain or heaviness
- Chills/hot flashes
- Tingling/numbness
- Pain
- Fear of dying
- Fear of going “crazy”
- Nausea
- Fears or phobias
- Obsessions/compulsions
- Thoughts racing
- Disorganization
- Procrastination
- Can’t hold onto an idea
- Anger/frustration
- Suspiciousness or mistrustfulness
- Problems trusting others
- Easily irritated/annoyed
- Aggressiveness
- Perfectionist behavior
- Lying
- Making/keeping friends
- Arguing with others
- Performing unusual rituals or habits
- Impulsiveness
- Excessive behaviors
- (Examples: spending, gambling)
- Delusions/hallucinations
- (Thinking/believing or seeing/hearing unusual things)
- Sexual problems
- Self injurious behaviors
- Shyness
- Social skills
- Social support (family/friends)
- Stealing
- Strange, weird, or peculiar
- behavior
- Confusion/can’t think
- clearly
- Feeling “not real”
- Feeling detached from yourself
- Feeling “hyper”
- Financial problems
- Grief/bereavement
- Health problems
- Impact of your problems on others
- Losing track of time
- Problems with memory
- Unpleasant thoughts that won’t go away
- Bothered by recurring thoughts
- Job/career problems or indecision
- Destruction of property
- Self-criticism
- Family problems
- Marital/relationship
- problems
- Parent/child problems
- Use of alcohol
- Use of drugs
- Blackouts
- Physical abuse
- Sexual abuse
- Partner abuse
- Trouble with the law
- Experienced/witnessed
- trauma
- Loss/death of someone close
- Other
Current Life Experiences
I live in:
- No Answer
- Apartment
- House
- Condo/Townhouse
- Mobile Home
- Rooming House
- Other
I live with...
Name(s) and age(s) of person(s) I live with
Their relationship(s) to me
Problems I'm facing:
My sources of satisfaction
My sources of stress
My leisure activities
My current life goals
What I hope to gain from counseling/therapy
History of Counseling/Therapy
Are you currently being treated by a counselor, psychologist, psychiatrist, and/or other physician for the problems noted above?
- No Answer
- Yes
- No
If yes, please provide the following information:
Date Name of Professional Address Treatment Type

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Please provide information regarding previous treatment you have received from a counselor, psychologist, psychiatrist, or other medical or mental health professional for this or other problems:
Date Profession Address Treatment Type Why Treatment Ended

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Have you ever been hospitalized for treatment of an emotional or mental disorder?
- No Answer
- Yes
- No
If yes, please provide the following information:
Date Hospital/Facility Name Address

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Medical History
Please complete the information below regarding past and current medical conditions and treatment:
Medical History
Dates Treatment Physician Name/Address Condition Results

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Please list all current prescription and over the counter medication use:
Beginning Date Medication Dose Frequency of Use Condition Treated

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Please list any previous prescription and over the counter medication use significant to your counseling/therapy:
Date From Date To Medication Dose Frequency Condition

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Please list any current or previous use of street drugs, tobacco products, or alcohol
Dates Type Used Frequency Amount Used When Ended Comments

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Please carefully read the statement below
I understand that I am responsible for all fees for services provided to me. I have read, understand, and agree to comply with the fee policies, and the No Show/Cancellation Policy. I also acknowledge I have read the Consent to Treatment form and the Notice of Privacy Practices for Protected Health Information. By signing this document, I indicate that I have reviewed, understand, and agree to comply with the policies in this disclosure statement/agreement, and that I consent to treatment for myself or my child.
Full Name*
First Last
Full Name (Minor)
First Last
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Name
This field is for validation purposes and should be left unchanged.

Date	Name of Professional	Address	Treatment Type

Date	Profession	Address	Treatment Type	Why Treatment Ended

Date	Hospital/Facility Name	Address

Dates	Treatment	Physician Name/Address	Condition	Results

Intake Form

Current Issues

Adult Problems Checklist

Current Life Experiences

I live with...

History of Counseling/Therapy

Medical History

Please carefully read the statement below

Philadelphia Institute for Individual, Relational & Sex Therapy

Contact Info