Psychotherapy Intake Form (Page 4 of 4) in pdf

PSYCHOTHERAPY INTAKE FORM

Social History

Are you currently employed?

Yes

If yes, what is your current employment?___________________________________________________

Rate your job satisfaction on a scale from 1-10 (with 10 being fully satisfied):_________________

Are you currently in a romantic relationship?

Yes

If yes, how long have you been in your current relationship?___________________________________

Rate your relationship satisfaction on a scale of 1-10 (with 10 being fully satisfied):_______________

Do you currently live alone?

Yes

If no, please list relationship to other household members (for example, my partner, my uncle, my

children, roommates, etc.):______________________________________________________________

____________________________________________________________________________________

Do you consider yourself a spiritual person?

Yes

Do you have a religious affiliation?

Yes

If yes, please specify?__________________________________________________

Have you experienced any life changes or stressful events recently?

__________________________________________________________________________________________

What kind of activities or coping strategies do you use when you are stressed or overwhelmed?

__________________________________________________________________________________________

What do you hope to be different about you or your life by the end of therapy?

__________________________________________________________________________________________

Psychotherapy Intake Form Page 4