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Standard Intake Questionnaire
What brings you to counseling at this time? Is there something specific such as a particular event? Be as detailed as you can.
What are your goals for counseling?
Have you seen a mental health professional before?
Specify all medications and supplements you are presently taking and for what reason.
If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.
Who is your primary care physician? Please include type of MD, name and phone number.
Do you drink alcohol? Do you use recreational drugs?
Do you have suicidal thoughts?
Do you have thoughts or urges to harm others?
Have you ever been hospitalized for a psychiatric issue?
Is there a history of mental illness in your family?
If you are in a relationship, please describe the nature of the relationship and months or years together.
Describe your current living situation. Do you live alone, with others. With family, etc…
What is your level of education? Highest grade/degree and type of degree.
What is your current occupation? What do you do? How long have you been doing it?
Please check any of the following you have experienced in the past six months
Isolation from others
Tearful or crying spells
Date Format: MM slash DD slash YYYY