Psychotherapy Intake Form (Page 3 of 4) in pdf

Psychotherapy Intake Form Page 3

PSYCHOTHERAPY INTAKE FORM

Check any of the following you have experienced in the past 30 days:

Hospitalization for severe stress or suicidality

Loss of interest in previously enjoyed activities

Overwhelming sadness

Crying spells

Significant change in weight

Problems in your relationships with friends or family

Overwhelming anxiety, nervousness, worry, or fear

Sudden unexpected panic spells

Frequent physical complaints (headaches, pain, etc)

Intrusive unwanted thoughts or images

Sleep changes and/or difficulties

Racing thoughts

Sexual concerns

Thoughts of suicide

Irritability or easily frustrated

Concerns related to sexual or gender identity

Mood swings

Grief

Overspending

Self-injury (i.e. cutting, burning, etc.)

Family History

Please check any issues that currently exist or have existed within your family:

Condition:

Family Member(s):

Depression

______________________________________________________

Bipolar disorder

______________________________________________________

Anxiety

______________________________________________________

Alcohol/Drug Abuse

______________________________________________________

History of suicide attempts

______________________________________________________

Eating disorder

______________________________________________________

Schizophrenia

______________________________________________________

Other:

______________________________________________________

Psychotherapy Intake Form Page 3