CLIENT INTAKE FORM
Disclaimer: Thank you for your interest in being a client of AB Clinic. This form is used to collect
information about new clients and for internal purposes only. The information you provide is
confidential and will be treated accordingly.
Some information about us – We are a group of trained psychologists and psychotherapists
having undergone formal training to conduct therapy with people. Therapy is a collaborative
process in which we explore your feelings, thoughts, and behavioral patterns. As a therapist, we
will create a safe, supportive, and non-judgmental space for you to meet your goals.
PERSONAL INFORMATION
Name: ______________________ Birthdate: __________ Age: ______ Gender:_________
Marital status: ☐ Never married ☐ Partnered ☐ Married ☐ Separated ☐ Divorced ☐ Widowed
Referred by (if any): ____________________________________________
Number of children: _____ Ages: _______________________
Current address: ______________________________________________
Phone Number: ______________________ May we leave a message? ☐ Yes ☐ No
Email: ______________________ May we email you?* ☐ Yes ☐ No
Emergency contact: _______________________ Phone Number: _____________________
Have you received psychological services, professional counseling, psychiatric services,
or any other mental health services in the past? ☐ Yes ☐ No
-If so, please specify your reason for the same: ______________________________________
Are you currently taking any psychiatric prescription medication? ☐ Yes ☐ No
-If yes, please list: _____________________________________________________________
Have you been prescribed psychiatric prescription medication in the past? ☐ Yes ☐ No
-If yes, please list: _____________________________________________________________
Have you been psychiatrically hospitalized in the past? ☐ Yes ☐ No
-If yes, please list dates and locations: _____________________________________________
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GENERAL HEALTH INFORMATION
Provide the name, address, and telephone number of your primary care physician:
____________________________________________________________________________
How is your physical health? ☐ Poor ☐ Unsatisfactory ☐ Satisfactory ☐ Good ☐ Very good
Please list any persistent physical symptoms or health concerns:
Are you on any medication for physical/medical issues? ☐ Yes ☐ No
-If yes, please list: _____________________________________________________________
Are you having any problems with your sleep habits? ☐ Yes ☐ No
-If yes, select the options that apply: ☐ Sleep too much ☐ Sleep too little ☐ Poor quality
☐ Disturbing dreams ☐ Other: _______________________________
Are there any changes or difficulties with your eating habits? ☐ Yes ☐ No
-If yes, select the options that apply: ☐ Eating less ☐ Eating more ☐ Bingeing ☐ Restricting
☐ Other: ________________________________________________
Have you experienced a weight change in the last two months? ☐ Yes ☐ No
Do you exercise regularly? ☐ Yes ☐ No
-If yes, how many days per week do you exercise? ___ How much time per session? _______
Do you consume alcohol regularly? ☐ Yes ☐ No
-In one month, how many times do you have four or more drinks in a 24-hour period? ___
How often do you engage in recreational drug use? ☐ Daily ☐ Weekly ☐ Monthly ☐ Rarely
☐ Never
What kinds of recreational drugs do you use? ____________________________________
Are you currently in a romantic relationship? ☐ Yes ☐ No
-If yes, how long have you been in this relationship? _____________
In the last year, have you had any major life changes (e.g., new job, moving, illness,
relationship change, etc.)? ______________________________
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SYMPTOMS
Check any that apply to you:
☐ Depressed mood ☐ Attachment issues ☐ Time loss
☐ Panic attacks ☐ Anger management ☐ Body complaints
☐ Memory lapse ☐ Family concerns ☐ Homicidal/Suicidal
☐ Sleep disturbance ☐ Relationship concerns thoughts
☐ Mood swings ☐ Work concerns ☐ Excessive worry
☐ Phobias ☐ Eating difficulties ☐ Alcohol/drug abuse
☐ Trouble planning ☐ Anxiety ☐ Traumatic event
Any other symptoms different from the above-mentioned?
________________________________
Have you had any suicidal thoughts recently? ☐ Yes ☐ No
-If yes, how often? ☐ Frequently ☐ Sometimes ☐ Rarely
Have you ever had suicidal thoughts in the past? ☐ Yes ☐ No
-If yes, how long ago? ________________________________
-How often did you have these thoughts? ☐ Frequently ☐ Sometimes ☐ Rarely
FAMILY MENTAL HEALTH HISTORY
Have any of your family members had any of the following issues? If so, specify the family
member affected.
☐ Depression ________________________________
☐ Suicide ________________________________
☐ Anxiety disorder ________________________________
☐ Bipolar personality disorder ________________________________
☐ Panic attacks ________________________________
☐ Alcohol/substance abuse ________________________________
☐ Eating disorder ________________________________
☐ Trauma ________________________________
☐ Domestic violence ________________________________
☐ Sexual abuse ________________________________
☐ Obesity ________________________________
☐ Obsessive-compulsive disorder ________________________________
☐ Schizophrenia ________________________________
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PERSONAL DETAILS
Do you practice a religion? ☐ Yes ☐ No If yes, what’s your faith? ______________________
Are you currently employed? ☐ Yes ☐ No
List your 3 interests and hobbies:
List your 2 strengths and what you like most about yourself:
List areas you feel you need to develop:
What are some ways you cope with life obstacles and stress?
What are your goals for therapy/what would you like to accomplish?
ACKNOWLEDGMENT
By signing below, I am acknowledging that I have chosen to receive mental health services in the
form of evaluation and psychotherapy from the clinic. My decision is voluntary, and I understand
that I may terminate these services at any time. I also understand that during the course of
treatment, I may need to discuss material of an upsetting nature in order to resolve my problems.
Further, I understand it cannot be guaranteed that I will feel better after the completion of
treatment.
Client name: ______________________ Date: _______________
Client signature: ______________________
Guardian name (if required): ______________________ Guardian signature _____________
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