Intake questionnaire

Simon R. Downes, Ph.D., Psychologist simondownesphd@gmail.com
Intake questionnaire:

Updated: July 24, 2015

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

These questions are for my records only and are confidential. Feel free to leave blank any questions that you do not want to answer. If any question does not apply to you, please, write “n/a” or “none”. Please take your time to answer these questions, as they are very helpful to get to know you, and for understanding your situation as well as I can.
Basic Information

Name:
Birth date:
Your address:
Your home phone/may I leave a message?
Your cell phone/may I leave a message?
Your e-mail:
Your age:
Male/Female:
How did you hear about this practice/ who referred you to this practice?
Your marital Status:
Number of Children:

History of therapy

Is this your first time for counseling or psychotherapy?
If no, when have you had counseling before?
Are you currently receiving therapy from another mental health professional?
Are you currently taking any psychotropic medications?
If yes, please list the medications and the dosage
Have you ever taken any psychotropic medications?
Basic health history
1. How is your physical health?
2. Do you have any health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.)?
3. Do you have a regular exercise routine? If so, please, describe:
4. Do you have any problems with appetite or eating? If so, please, describe:
5. Do you regularly use alcohol? Other substances? If so, please, describe:
6. Do you have any sleep problems? If so, please, describe:
7. Do you ever thinking about killing yourself? Have you ever attempted to kill yourself? How?
8. Are you having any relational problems? If so, please, describe:
9. What stressors do you have presently (e.g., work, children, etc.)? Please, describe:
10. Have you ever been psychiatrically hospitalized?
If yes, when?

Have you experienced any of these in the past? (If yes, please describe) (If yes, please describe)

Extreme depressed mood
Strong mood swings
Extreme anxiety
Panic attacks
Phobias
Severe sleeping difficulties
Hallucinations
Alcohol/Substance Abuse
Eating Disorder
Body Image Problems
Repetitive Thoughts (e.g., Obsessions)
Repetitive Behaviors (e.g., Frequent Checking, Hand-Washing)
Homicidal Thoughts
Suicide Attempt

Other information

What is your level of education?
What do you do for living?
Has any member of your immediate family received any psychiatric/psychological treatment?
Do you like yourself?
How do you see yourself?
How do you cope with stress?
What are your treatment goals?
What do you read?
What do you watch on TV?
What, if any, is your religious/spiritual background?
Thank you for taking the time to fill out this form.

END

Simon R. Downes, Ph.D., Psychologist
simondownesphd@gmail.com

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