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Intake Form

Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Please fill out this form and bring it to your first session.

First Name *

Middle Initial

Last Name *

Name of parent/guardian (if under 18 years):

First Name *

Middle Initial

Last Name *

Birth Date *

Age

Gender

Marital Status *Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed

Please list any children/age:0 / 180

Street Address

Apartment, suite, etc

City

State

ZIP / Postal Code

Home Phone:

May we leave a message?YesNo

Cell/Other Phone:

May we leave a message?YesNo

E-mail*Please note: Email correspondence is not considered to be a confidential medium of communication.

May we email you?YesNo

Referred by (if any):

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *NoYes, previous therapist/practitioner:

Are you currently taking any prescription medication? *YesNo

Please list:

Have you ever been prescribed psychiatric medication? *YesNo

Please list and provide dates: *

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

1. How would you rate your current physical health? *PoorUnsatisfactorySatisfactoryGoodVery good

Please list any specific health problems you are currently experiencing:

2. How would you rate your current sleeping habits? *PoorUnsatisfactorySatisfactoryGoodVery good

Please list any specific sleep problems you are currently experiencing:

3. How many times per week do you generally exercise?

What types of exercise to you participate in

4. Please list any difficulties you experience with your appetite or eating patterns

5. Are you currently experiencing overwhelming sadness, grief or depression?YesNo

If yes, for approximately how long?

6. Are you currently experiencing anxiety, panic attacks or have any phobias?YesNo

If yes, when did you begin experiencing this?

7. Are you currently experiencing any chronic pain?YesNo

If yes, please describe

8. Do you drink alcohol more than once a week?YesNo

9. How often do you engage recreational drug use?DailyWeeklyMonthlyInfrequentlyNever

10. Are you currently in a romantic relationship?YesNo

If yes, for how long?

On a scale of 1-10, how would you rate your relationship?

11. What significant life changes or stressful events have you experienced recently

FAMILY MENTAL HEALTH HISTORY:

In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

Alcohol/Substance Abuse *YesNo

List Family Member

Anxiety *YesNo

List Family Member

Depression *YesNo

List Family Member

Domestic Violence *YesNo

List Family Member

Eating Disorders *YesNo

List Family Member

Obesity *YesNo

List Family Member

Obsessive Compulsive Behavior *YesNo

List Family Member

Schizophrenia *YesNo

List Family Member

Suicide Attempts *YesNo

ADDITIONAL INFORMATION:

1. Are you currently employed?YesNo

If yes, what is your current employment situation:

Do you enjoy your work? Is there anything stressful about your current work?

2. Do you consider yourself to be spiritual or religious?YesNo

If yes, describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weakness?

5. What would you like to accomplish out of your time in therapy?

Save as Draft

Please do not fill in this field.

Looking for extra support and guidance through a challenging situation. Let's Talk!

408-204-4248

Tricia Peterson, MFT -

441 N. Central Avenue Suite 9
Campbell, CA 95008
USA

tricia@triciapeterson.com

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