Psychotherapy Client Intake Questionnaire

Please complete this Intake. Progressive Option Support Services views all the information that you provide us with as strictly confidential on this HIPAA compliant submission platform.

Personal Information

Please enter your first name.
This field is required.
Please enter your last name.
This field is required.
Required if client is under 18 (Parent/Legal Guardian).
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Address
Address Line 1
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Address Line 2
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City Name
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State
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Postal Code
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Country
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Your primary contact number.
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Optional secondary contact number.
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May we leave a phone message?
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Please note: Email correspondence is not considered to be confidential medium of communication.
May we leave an email message?
Please select Yes or No.
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Please select your date of birth.
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Please enter your age.
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Please specify your gender identity.
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Please select your marital status.
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Insurance Information

Please specify how you were referred.
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Please enter the primary insured’s first and last name.
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Please select your relationship to the insured.
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Other
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Please select the primary insured’s date of birth.
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Please select your insurance company.
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Other
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Please enter your insurance ID number.
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History

Previous mental health services?
Have you received any previous mental health services?
This field is required.
Please provide the relevant details below.
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Current prescription meds?
Are you currently taking any prescription medications?
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Please provide the relevant details below.
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Past psychiatric meds?
Have you taken psychiatric medications in the past?
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Please provide the relevant details below.
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Psychiatric hospitalization?
Have you ever been hospitalized for psychiatric reasons?
This field is required.
Please provide the relevant details below.
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Suicidal thoughts?
Have you had any thoughts of self-harm or suicide?
This field is required.
Please provide the relevant details below.
This field is required.
Previous Mental Health Services?
Have you previously received any type of mental health services psychotherapy, psychiatric services, etc?
This field is required.
Please provide the relevant details below.
This field is required.
Current Prescription Medications?
Are you currently taking any prescription medication?
This field is required.
Please provide the relevant details below.
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Past Psychiatric Medications?
Have you ever been prescribed psychiatric medication?
This field is required.
Please provide the relevant details below.
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Psychiatric Hospitalization History?
Have you ever been hospitalized for a psychiatric issue?
This field is required.
Please provide the relevant details below.
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Suicidal Thoughts or Tendencies?
Have you ever had or are you currently experiencing thoughts of suicide?
This field is required.
Please provide the relevant details below.
This field is required.
Previous History?
Have you previously received any type of mental health services psychotherapy, psychiatric services, etc?
This field is required.
Please provide the relevant details below.
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General and Mental Health Information

Explain in a few short sentences why you are seeking therapy services at this time.
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How would you rate your current physical health? (Please circle one)
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Please list any specific health problems you are currently experiencing:
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How would you rate your current sleeping habits? (Please select one)
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Please list any specific sleep problems you are currently experiencing:
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How many times per week do you generally exercise?
This field is required.
What types of exercise do you participate in?
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Please list any difficulties you experience with your appetite or eating problems:
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Depression, Sadness, or Grief?
Are you currently experiencing overwhelming sadness, grief, or depression?
This field is required.
Please provide the relevant details below.
This field is required.
Anxiety or Panic Symptoms?
Are you currently experiencing anxiety, panic attacks or have any phobias?
This field is required.
Please provide the relevant details below.
This field is required.
Chronic Pain?
Are you currently experiencing any chronic pain?
This field is required.
Please provide the relevant details below.
This field is required.
Alcohol Consumption
Do you drink alcohol more than once a week?
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Please provide the relevant details below.
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How often do you engage in recreational drug use?
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Current Relationship?
Are you currently in a romantic relationship?
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How Long?
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On a scale of 1 -10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
This field is required.

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 (e.g. father, grandmother, uncle, etc.)

What significant life changes or stressful events have you experiences recently?
This field is required.
Alcohol/Substance Abuse?
This field is required.
Please List Family Members (if yes)
This field is required.
Anxiety
This field is required.
Please List Family Members (if yes)
This field is required.
Depression
This field is required.
Please List Family Members (if yes)
This field is required.
Domestic Violence
This field is required.
Please List Family Members (if yes)
This field is required.
Eating Disorders
This field is required.
Please List Family Members (if yes)
This field is required.
Obesity
This field is required.
Please List Family Members (if yes)
This field is required.
Obsessive Compulsive Behavior
This field is required.
Please List Family Members (if yes)
This field is required.
Schizophrenia
This field is required.
Please List Family Members (if yes)
This field is required.
Suicide Attempts
This field is required.
Please List Family Members (if yes)
This field is required.

Additional Information

Are you currently employed?
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Do you enjoy your work? Is there anything stressful about your current work?
This field is required.
If yes, what is your current occupation and how long have you been doing it?
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Do you consider yourself to be spiritual or religious?
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describe your faith or belief:
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What are some of your strengths?
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What are some of your weaknesses?
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What do you wish to accomplish during during therapy?
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This field is required.
This field is required.