Innovative Therapy Services

Client Intake Form

Please complete the following Client Intake Form. Upon completion of the form, you will receive an email confirmation with additional information regarding the intake process. Please be as thorough as possible when answering the questions below. If you have any questions regarding this form, please contact us.

First Name
Last Name
Middle Initial
Birth Date	(MM/DD/YYYY)
Age
Social Security Number
Gender	Male Female
Address Line 1
Address Line 2
City
State
Zip
Home Phone	May we leave a message? Yes No
Mobile Phone / Other	May we leave a message? Yes No
Email	May we email you? Yes No
	Please note: Email correspondence is not considered to be a confidential medium of communication and will be utilized in rare cases only.
Marital Status	Never Married Domestic Partnership Married Separated Divorced Widowed
Children	If Applicable (list first names and ages below)


	Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No
	If yes, who was your previous therapist/practitioner?

	Why did you stop treatment? (please explain)

	Are you currently taking any prescription medication? Yes No
	If yes, please list medications below:

	Have you ever been prescribed psychiatric medication? Yes No
	If yes, please list medications and dates below:


	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 (father, grandmother, uncle, etc.).
	Alcohol Yes No
	Anxiety Yes No
	Depression Yes No
	Domestic Violence Yes No
	Eating Disorders Yes No
	Obesity Yes No
	Obsessive Compulsive Behavior Yes No
	Bipolar Disorder Yes No
	Suicide Attempts Yes No

	GENERAL HEALTH AND MENTAL HEALTH INFORMATION:
	How would you rate your current physical health?
	Poor Unsatisfactory Satisfactory Good Very Good
	Please list any specific health problems you are currently experiencing:

	How would you rate your current sleeping habits?
	Poor Unsatisfactory Satisfactory Good Very Good
	Please list any specific sleep problems you are currently experiencing:

	Please list any difficulties you experience with your appetite or eating patterns:

	Are you currently experiencing overwhelming sadness, grief, or depression? Yes No
	If yes, for approximately how long?
	Are you currently experiencing anxiety, panic attacks, or have any phobias? Yes No
	If yes, when did you begin experiencing this?

	Are you currently experiencing any chronic pain? Yes No
	If yes, please describe:

	Do you drink alcohol more than once a week? Yes No
	Type: Frequency:
	How often do you engage recreational drug use?
	Daily Weekly Monthly Infrequently Never

	ADDITIONAL INFORMATION:
	Are you currently employed? Yes No
	If yes, what is your current employment situation?

	Do you enjoy your work? Is there anything stressful about your current work?

	If you are a student what school do you attend? What grade/year?

	Extracurricular activities (if any):

	Do you consider yourself to be spiritual or religious? Yes No
	If yes, please describe your faith or belief:

	What do you consider to be some of your strengths?

	What do you consider to be some of your weaknesses?

	Why have you sought therapy treatment at this time?

	What would you like to accomplish out of your time in therapy?

	What else do you feel I should know about you to best help you as your therapist?


	INSURANCE INFORMATION
Insurance Company Name
Insurance Company Phone
ID#
Group #
	Policy Holder Information Please check this box if the client and the policy holder are the same, otherwise please complete the policy holder information below.
First Name
Last Name
Address Line 1
Address Line 2
City
State
Zip
Phone
Employer
Social Security Number
Birth Date	(MM/DD/YYYY)
Gender	Male Female
Client's Relationship to Policy Holder