Therapy Intake Form Therapy Intake Form - Confidential Therapy Intake Form - Confidential To be completed by the client without influence. Please complete the information on this form. These are some of the questions we might ask you during your first session in order to help you achieve your goals better. Completing this form accurately helps reduce the time spent on these questions during your session, so we can focus on other areas. It may seem long, but most of the questions require only a check, so it will go quickly. If you have any questions, please send us a WhatsApp message on 08096642604 and we would respond ASAP. SECTION 1: PERSONAL INFORMATION User Code (Please do not include your name). * How old are you? * Birthday Address * Gender * Height (Feets) Weight (Kg) Referred By (Leave blank if you were not referred by anybody) Emergency Contact (Name) * Emergency Contact (Number) * Emergency Contact (Email) Relationship With Emergency Contact * SECTION 2: WHY ARE YOU SEEKING HELP? Reason One * Please write in details to enable us to have an idea of how to help you efficiently Reason Two Please write in details to enable us to have an idea of how to help you efficiently Reason Three Please write in details to enable us to have an idea of how to help you efficiently History (Please provide details on the history i.e. when and how did your worries start. Kindly include details such as date) * So far, what solutions have been helpful? * Treatment Goals (What would you like us to focus on during sessions) * Current Symptoms Checklist (Please check all that applies to you) * Depressed mood Excessive worry Impulsivity Sleep pattern disturbance Loss of interest Decreased libido Concentration problems/forgetfulness Change in appetite Excessive guilt Decreased need for sleep Crying spells Increase risky behaviour Hallucinations Unable to enjoy activities Anxiety/ panic attacks Avoidance Increased libido Racing Thoughts Suspiciousness Excessive energy Increased irritability Excessive need for sleep Fatigue Lack of motivation How would you classify your eating habit? * Poor Excellent Good How would you classify your sleep? * Excellent Good Poor SECTION 3: SUICIDE AND HOMICIDAL RISK ASSESSMENT Have you ever had feelings or thoughts that you didn't want to live? * No Maybe Yes If YES or MAYBE to the question above, please answer the remaining 11 questions on this section. If NO, please skip to the next section (skip the next 11 questions). Do you currently feel hopeless and/or worthless? Yes No Maybe Do you currently feel that you don't want to live? Maybe Yes No How often do you have these thoughts? Daily Every other day Weekly Bi-weekly Monthly Other When was the last time you had thoughts of dying? Has anything happened recently to make you feel this way? Would anything make it better? Please specify Have you ever thought about how you would kill yourself? Is the method you would use readily available? Have you planned a time for this? Have you ever tried to kill or harm yourself in the past? Have you ever had the thought to kill or harm someone else? * Yes No If yes, when did you last have the thought SECTION 4: MEDICAL HISTORY List all current prescription medications and how often you take them: (if none, write none) * List all current over the counter medications and supplements and how often you take them: (if none, write none) * Current medical challenges (if none, write none) * Past medical challenges, nonpsychiatric hospitalization, or surgeries (if none, write none) * When your mother was pregnant with you, were there any complications during the pregnancy or birth? (if none, write none) * Do you have any concerns about your physical health that you would like to discuss with us? (if none, write none) * SECTION 5: PAST PSYCHIATRIC HISTORY Have you ever had an outpatient treatment? * No Yes If yes, please provide details Have you ever had a psychiatric hospitalization? * Yes No If yes, please provide details Past/ Present Psychiatric Medications (check all that applies) Antidepressants Antipsychotics ADHD medications Mood Stabilizers Sedative/Hypnotics Antianxiety medications If you have ever taken any of the above medications, please indicate the dates, dosage, and how helpful they were (if you can't remember all the details, just write in what you do remember). Has anyone in your family (immediate or extended) been diagnosed with or treated for (check all that applies) Alcohol Abuse Depression Anxiety Suicide/ Suicidal Thoughts Violence Bipolar Affective Disorder Other Substance Abuse Anger Management Post Traumatic Stress Disorder Schizophrenia Others SECTION 6: YOUR EXERCISE LEVEL Do you exercise regularly? * Yes No How many days a week do you get exercise? How much time each day do you exercise? SECTION 7: SUBSTANCE USE Have you ever been treated for alcohol, drug use? * Yes No If yes, for which substances? Please provide dates Check if you have ever tried any the following (check all that applies) LSD or Hallucinogens Alcohol Tranquilizer/sleeping pills Marijuana Tobacco (Cigarettes, pipes, cigar, or chewing) Cocaine Pain killers (not as prescribed) Methadone Methamphetamine Heroin Stimulants (pills) Ecstasy How many caffeinated beverages do you drink a day? Have people annoyed you by criticizing your drinking or drug use? Maybe Yes No Have you ever felt you ought to cut down on your drinking or drug use? Yes No Maybe Have you ever felt bad or guilty about your drinking or drug use? Maybe No Yes SECTION 8: FAMILY BACKGROUND AND CHILDHOOD HISTORY How much time did you spend with your immediate family when growing up? * Averagely Not so much Very much How many siblings do you have and what is your position in the family? * Did your parents' divorce or seperate? * Yes No If yes, how old were you when they divorced or separated? If your parents divorced or separated, who did you live with while growing up? Describe your mother and your relationship with her * Describe your father and your relationship with him * Describe your relationship with your siblings * Has anyone in your immediate family died? * No Yes If yes, please state who and when Check any of the following that applied during your childhood/adolescence * Unhappy Childhood Alcohol Abuse Adventurous Legal Challenges Strong Religious Convictions School Challenges Drug Abuse Happy Childhood Emotional/ Behavioral Challenges Family Challenges Medical Challenges SECTION 9: TRAUMA HISTORY Do you have ANY traumatic experiences? * No Yes If yes, please provide details (please include details if there are multiple traumatic experiences) SECTION 10: EDUCATION HISTORY What is your highest educational level or degree attained? * How would you grade your overall performance? * Above Average Below Average Average How would you grade your performance in primary school? * Below Average Above Average Average How would you grade your performance in secondary school? * Average Above Average Below Average Did you date much in school? * Were you bullied at any time in school? * Yes No If yes, please provide details of the bullying experience Did you bully anyone at any time in school? * Yes No If yes, please provide details of the bullying experience SECTION 11: OCCUPATIONAL HISTORY Are you currently * Working Unemployed Retired A student Unable to work Self-employed How long in present position? * What is/was your occupation? SECTION 12: RELATIONSHIP HISTORY AND CURRENT FAMILY Are you currently * Single Married Divorced Partnered Widowed Other How long? * Are you sexually active currently? * Describe your relationship with your spouse or significant other, if currently in a relationship (if none, write none) * Do you have children? * No Yes If yes, please list their ages * Describe your relationship with your child/ children (if any) SECTION 13: LEGAL/ FINANCIAL Do you have any pending legal problems? * No Yes Do you have any pending debt problems? * No Yes SECTION 15: SPIRITUAL LIFE Do you belong to a particular religion or spiritual group? * No Yes Do you find your involvement helpful during this trying period, or does the involvement make things more difficult or stressful for you? * Helpful Very much helpful Unhelpful Very much unhelpful Is there anything else that you would like us to know? (if none, write none) * Where did you hear about us? * Friends and FamilyGoogle SearchInstagramFacebookYouTubeLinkedInReferral from a Professional (e.g. Doctor, Counsellor, Pastor, etc.)Others * I certify that the information provided on this form is true to the best of my knowledge * I acknowledge the use of the information provided on this form for my therapy sessions * I acknowledge that I have read and understand the informed consent (request a copy from the admin if you don't already have one) If you are human, leave this field blank. Submit Δ
