Initial Intake & Mental Health Screening

Welcome. This intake helps us understand what you are bringing to therapy and how we can best support you. Take your time, share what feels comfortable, and skip anything you would rather discuss in person — we can revisit any section together.

Client Information

Full legal name:

Date of birth:

Preferred name:

Pronouns:

Email:

Phone:

Mailing address:

Occupation:

Employer / school:

Marital status:

Single

Partnered

Married

Separated / divorced

Widowed

Prefer not to say

Emergency Contact

Contact name:

Relationship to you:

Phone:

Referral Source

How did you hear about us? Select all that apply.

Self-referred

Physician / medical provider

Family member or friend

School or university counselor

Employer / EAP

Online directory or search

Other

Referring contact name:

Referring contact phone or email:

Presenting Concerns

In your own words, what brings you in today?

Symptom Onset & Course

When did this begin or get more difficult?

Severity right now (1 = mild, 10 = severe):

How often do these difficulties show up?

Daily

Most days

A few times per week

Occasional / situational

How is this affecting your daily life — work, relationships, sleep, eating?

Mental Health History

Anything from earlier in life you would like us to know?

Have you been in therapy before?

Yes

No

When (year):

Where / with whom:

Approximate duration:

Previous diagnoses, if any:

I have had a psychiatric hospitalization

If yes, please share what feels okay to share:

Sometimes thoughts of suicide or self-harm come up. Knowing this helps us care for you well — there are no wrong answers.

I have never had thoughts of suicide or self-harm

I have had such thoughts in the past, not currently

I have such thoughts occasionally

I have such thoughts frequently

If you would like to share more, you can write it here. You can also leave this blank and we can talk about it together.

Medications & Health

Current psychiatric medications — name, dose, prescriber:

Other medications, supplements, or vitamins:

Medical conditions or chronic health concerns:

Allergies:

Substance Use

Alcohol use:

Never

Rarely

Weekly

Daily

Cannabis or other recreational substances:

Never

Rarely

Weekly

Daily

I have received treatment for substance use

If yes, please share what is helpful for us to know:

Trauma History

If comfortable, please share any history of trauma. You may skip this entirely; we can revisit it together later when it feels right.

Support System

Who do you usually turn to when things are hard?

How would you rate your closest relationships overall (1 = strained, 5 = strong)?

Day-to-day, how connected do you feel?

Well connected

Somewhat connected

Often lonely

Mostly isolated

Lifestyle

Average hours of sleep:

Sleep quality:

Restful

Mixed

Often disrupted

Insomnia / hypersomnia

Appetite:

Normal

Reduced

Increased / emotional eating

Exercise frequency:

Daily

A few times per week

Occasionally

Rarely

Spiritual, religious, or cultural background that is meaningful to you:

Goals & Readiness

If therapy goes well, what would success look like for you?

Your readiness to begin therapy (1 = unsure, 10 = fully ready):

Any concerns or hesitations about starting therapy?

Mandatory Reporting Acknowledgement

Therapy is confidential, with a few exceptions explained below. Please review and confirm your understanding.

I understand that the therapist may need to act on disclosures involving abuse of a child or vulnerable adult

I understand that imminent risk of serious harm to myself or others may require additional steps to keep me and others safe

I understand that records may be requested by a court order

I agree to discuss any of the above with my therapist as needed

I have received written notice of these confidentiality limits

Signatures

Client signature:

Therapist signature:

Intake date:

I have completed this intake to the best of my ability

Thank you for taking the time to share. Whatever you have written is a solid starting point — we will go through it together and decide next steps at a pace that suits you.