Psychotherapy Intake Form (Page 2 of 4) in pdf

Psychotherapy Intake Form Page 2

PSYCHOTHERAPY INTAKE FORM

Medical Information

Have you previously participated in or received mental health services (ex: psychiatric care, individual

counseling, group therapy and/or substance abuse treatment)?

Yes

If yes, what types of services and approximately when?

__________________________________________________________________________________________

How would you describe your current physical health (please circle one):

Poor Unsatisfactory

Satisfactory

Good

Excellent

Please list any current medical conditions:

__________________________________________________________________________________________

Please list any medications you are currently taking (including prescription, over the counter, supplements):

__________________________________________________________________________________________

Choose the box that best describes your answer:

How often, on average, do you consume a drink containing alcohol?

Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

Check any of the following that you have used in the past year:

Marijuana

Cocaine

Non-prescription pain medication

Heroin

Methamphetamine

Other:___________________________________

If you use nicotine, have you been thinking about quitting?

Yes

Psychotherapy Intake Form Page 2