New Client Clinical Intake

Client Demographic Information

* Indicates required field

10b. Employment Status *

Self-Employed Part-Time Employment Full-time Employment "Under-the-Table" work

10c. If client is a student please include client's current grade level and name of school *

Insurance Information

11. Insurance Company *

12. Insurance ID# *

Complete questions 13-16 if primary insured is not the client

13. Full Name of Primary Insured (if other than client) *

First

Last

15. Date of Birth of Primary Insured (MM/DD/YYYY) *

14. Address of Primary Insured (if different than client's) *

Line 1

Line 2

City

State

Zip Code

Country

16. Primary Insured's Phone Number *

Mental & Physical Health History

Does client consume alcohol? *

If yes, describe age of first use and current amount and frequency *

Does client use recreational drugs? *

If yes, describe age of first use and current amount and frequency *

Does client use cigarettes/nicotine? *

If yes, describe age of first use and current amount and frequency *

PROBLEM CHECKLIST Clients 11 years and older, please rate the degree the problems below are impacting your life.
DO NOT COMPLETE IF CLIENT IS UNDER 11 YEARS OLD.

Choose One *

Option 1 Option 2 Option 3

I can't seem to control myself when I eat *

I enjoy taking risks and I don't worry about safety or negative consequences. *

Playing video games is more important than almost anything else in my life. *

I have set fires on purpose, just for fun. *

I feel restless most of the time. *

I avoid anything that is related to a trauma I experienced. *

I am disorganized and it affects my work and other parts of my life *

I have difficulty discarding items even if I have no use for them. *

I have bald patches because I pull my hair and/or my eyebrows. *

I am frequently tired or experience low energy. *

I rarely complete the things I start. *

I frequently do things that make me feel guilty and ashamed. *

I require very little sleep and feel driven all of the time. *

I frequently fall asleep during the day. *

I often do things over and over and can't stop. *

I lie a lot even though I don't really mean to do this. *

I often feel detached from reality, my surroundings, my mind, or my body. *

I am sometimes confused about my identity, perceptions, or memories. *

My mind races. *

I think I have a short attention span. *

Thoughts keep racing through my mind. *

I can't stop thinking about things that upset me. *

I have trouble controlling thoughts that upset me. *

I have experienced trauma but, I can't remember details. *

I have specific fears that are keeping me from living the life I want. *

I avoid certain social or performance situations. *

I am afraid to use public transportation. *

I feel guilty about things I did in my past and I can't tell anyone about this. *

I worry that I have a disease or other medical condition (without a confirmed medical diagnosis). *

It's impossible for me to relax; I typically feel tense, restless, irritable, or on edge. *

I feel agitated and driven. *

I almost always feel empty inside. *

I can't control my emotions and they can change from minute to minute. *

Sometimes when I'm anxious, I feel that my heart is beating uncontrollably. *

I feel worthless much of the time. *

I worry sometimes that I will hurt my children by accident. *

I often feel stick to my stomach. *

Doing my best is never good enough. *

I am disappointed with my lack of success. *

I feel that life isn't worth living. *

I am blamed for things that I don't do. *

I am frequently lonely. *

I am afraid of being abandoned. *

I need constant support from other people for my problems. *

I feel like my relationship with my partner/spouse is falling apart. *

I don't enjoy or desire close relationships, and I prefer to be alone. *

There is no love, romance, or respect in my relationship. *

I have been physically abused in the past. *

I don't really like talking to others and prefer just to listen. *

People are jealous of me. *

I am cut off from members of my family. *

No one understands me. *

I feel stuck in my job. *

My finances are a mess and I can't do anything about it. *

Sometimes I am impulsive and my behavior is reckless. *

I have made suicide attempts. *

I frequently get into verbal fights with people. *

I tend to fidget and have a hard time sitting still. *

I exercise all of the time in order to burn calories and keep off weight. *

Sometimes I find myself in a place and I don't know how I got there. *

I have a hard time cutting down on my drinking or drug use. *

My living space is very cluttered and I don't like to throw things away. *

I have rigid routines, schedules, and daily patterns that must be maintained no matter what. *

I spend hours and hours each day on social media and the Internet. *

I am sexually aroused when I expose myself to strangers. *

I grind my teeth and/or have other habits that show my tension. *

I have difficulty waking from a long sleep and feel disoriented when I do wake up. *

I sleep more than the average adult. *

I feel stressed most of the time. *

I sometimes experience memory loss that I have to cover up. *

I often can't think clearly and I'm having difficulty making decisions. *

I tend to avoid tasks that require too much effort. *

I often think about death and suicide. *

I can't seem to turn off my mind. *

I don't know where my life is going. *

I constantly worry about what is going to happen. *

I have lost a loved one and my grieving has become depression. *

I feel sweaty or flushed when I am anxious. *

I am anxious when performing or speaking in front of people. *

I am afraid of being criticized or rejected. *

I am anxious in crowded spaces. *

I feel like I will lose control or go crazy. *

My worrying causes me to have physical problems like stomachaches and headaches. *

I feel out of control and helpless. *

I feel sad and blue almost every day. *

I can't control my anger and I tend to explode when I am annoyed. *

People tell me that my emotional responses tend to be extreme. *

I feel guilty much of the time. *

I feel inadequate and worry about what other people think about me. *

I never seem to get anything right. *

I used to be happier. *

Even when I'm alone, I feel that someone is watching me. *

Nothing about me is right. *

I feel like my life keeps getting worse. *

I don't think that many people like me. *

I seem to always need other peoples's advice and feedback when I make decisions *

I'm only happy when I am in a romantic relationship *

People often deceive me or try to exploit me. *

I am suspicious or distrustful of other people, the government, etc. *

I don't feel safe communicating my personal needs and wants. *

I feel alone and isolated because I am not in a romantic relationship. *

I have always wanted close friends, but have a very hard time maintaining friendships. *

I am jealous of others. *

My moods negatively affect my functioning at work or school. *

I often miss work because I want to avoid my work conditions, my boss, or coworkers. *

I hate my job/I hate school. *

I'm afraid that I'm going to be fired. *

If I eat too much I want to vomit or use laxatives. *

I frequently get into physical fights with people. *

I frequently destroy objects just for the fun of it. *

I have been told that I often act without thinking. *

I have strict rules or rituals around food and eating. *

I repeatedly engage in time-consuming behaviors to decrease my anxiety or obsessive thinking. *

I never finish things that I start. *

I impulsively steal items that I don't actually need. *

I often find myself making involuntary noises, like clearing my throat over and over. *

People tell me that I speak too softly to be heard. *

I cannot easily have an orgasm. *

I spend most of my time alone. *

I have trouble falling or staying asleep. *

I sleepwalk or have night terrors. *

I often think that I might harm other people. *

People often tell me that I am reckless and don't think before I act. *

I see things other people say are not really there. *

I don't remember parts of my past. *

I am very focused on my body weight and shape. *

People tell me that I am always too negative. *

I forget to do things. *

I constantly worry about things that might go wrong. *

I recently experienced an event that was extremely traumatic. *

I worry all of the time even when I know worrying won't help. *

I worry about having a panic attack. *

When I am in certain situations I have panic attacks *

I am afraid to try new activities because I might embarrass myself. *

I am fearful of enclosed spaces. *

I am afraid I will die soon, although I am in good health. *

I think about suicide all of the time. *

I often feel overwhelmingly sad and hopeless. *

Nothing gives me pleasure anymore. I am no longer interested in activities or hobbies that I used to enjoy. *

I often feel numb and emotionally detached *

My hands frequently tingle or feel numb. *

I have chest pain or discomfort when I am anxious. *

I feel disgusted with myself, depressed, or very guilty after I eat. *

I am afraid of something specific (blood, vomit, needles, heights). *

I don't really care about my appearance anymore. *

I feel sad most of the time. *

I never seem to be able to relax. *

I feel like my problems will never go away. *

I avoid being close to people because I'm afraid of being ridiculed, shamed, or rejected. *

I like to have other people make decisions for me. *

I need to be the center of attention. *

If I share personal information it will be used against me. *

I constantly worry that my partner is cheating on me. *

I am in a situation where there is a real threat of being physically hurt. *

Even though I make every attempt to date and meet people I am still alone. *

I'll do anything to avoid being alone. *

There are people in my life that I can't ever forgive. *

I fail to meet my work or school responsibilities. *

I have a difficult time getting along with people at my work or school. *

I can't seem to get along with my boss and/or co-workers. *

I want to change jobs, but I'm worried about what could happen. *

I binge eat at least once per week. *

Sometimes I think my behavior is odd or strange. *

I find that stealing items is exciting, *

I have been told that I talk too much. *

I eat very quickly and frequently find myself uncomfortably full. *

I sometimes hurt myself by cutting or burning. *

I can't cut back or stop my gambling. *

I get extremely upset when my things are moved or rearranged. *

I eat alone because I am embarrassed to eat in front of other people. *

I am unable to become sexually aroused. *

I can't control my sex-related behavior that I feel are morally wrong. *

I have frequent disturbing nightmares. *

People often tell me to be still. *

I have some bad habits that are interfering with my life. *

I often have violent fantasies about hurting people I know. *

I sometimes forget everyday events and personal information. *

I am confused about my sexuality *

People tell me that my thoughts are not based in reality *

I see weird things. *

I constantly worry that people I love will be hurt. *

I recently experienced an event where I felt hopeless and terrified. *

I frequently worry or feel anxious. *

I fear embarrassment or humiliation in social settings. *

I avoid many things I would like to do because of my anxiety and fears. *

I am afraid that I will be unable to escape certain situations. *

I am fearful of leaving my home. *

My fears cause me to feel overwhelmed and confused. *

I only feel good about myself if I am thin. *

I often feel so hopeless and depressed that I don't want to live anymore. *

I withdraw from family and friends. *

I have difficulty expressing my emotions. *

I have pain in one or more areas of my body that doctors can't explain. *

I sweat a lot in social situations. *

I don't think I'm a good parent. *

I don't really enjoy anything anymore. *

I wish I were different. *

I feel like people are out to get me. *

I feel that I am unattractive. *

I think that there are people who want to hurt me. *

I am shy and this keeps me from doing things that I would like to do. *

I have a hard time maintaining relationships with friends and family. *

If I disagree with the people I know, they won't like me. *

I expect people to admire me. *

People often verbally attack me or talk behind my back. *

My partner and I have trust issues. *

I am in a situation where there is consistent emotional abuse. *

It's difficult for me to interpret what other people are thinking or feeling. *

I am easily influenced by the people around me. *

I feel out of place around people. *

I'm afraid of being rejected or criticized at work. *

I can't hold a job and/or I've been frequently fired. *

Even when I try hard, I seem to fail. *

I am sexually harassed at my work *

I have been told that I am controlling. *

Additional Comments. Include current significant stressors such as financial problems, legal issues, troubles with hygiene, staying neat, staying tidy and organized,, exhibits of cognitive distortions (etc) *

Who referred Client? *

Is therapy/counseling mandated? *

Client's 1st goal - Develop insight and gain skills to manage problems with *

Client's 2nd goal - Develop coping skills to manage problems with *

Requested Services *

Individual Adult Counseling Individual Youth Counseling Couple's Counseling

Required Services *

Family Counseling Group Counseling Substance/Addiction Counseling

Name of Person Completing Intake *

First

Last

Date *

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New Client Clinical Intake

New Client Clinical Intake