Intake Questions (Getting to know you better!)


Please take some time to reflect and answer the questions. This will allow the therapist more insight on what your needs are, the nature, severity, and impact of your difficulties, to assess any functional impairment, and your stressors, along with your strengths and resources. 

By filling out Intake questions ahead of time, this will allow the therapist more face-to-face time with you at your first visit to help build your treatment plan with you and begin your journey to emotional wellness.

There are 23 questions which should take you about 10-15 minutes to complete.

 

Response is required below.
Please enter a valid email address below.
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Please select at least no options.
Please don't exceed more than 0 options.
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Name
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*

Where do you live?

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Who lives with you? (if you live with no one or less than 5 people, put NA on the other lines)
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Are your basic needs being met or is there anything you would like to add regarding this?(including economic status: shelter, food, clothing, financial)
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Employment (or other)

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What is your highest level of education?

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Please don't exceed more than 40 options.
 

Significant personal relationships.
Who is important in your life and how do you relate to one-another?

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*

Strengths and resources, including the extent and quality of social networks
What do you do well?
What is going well in your life?
Who do you consider supportive?

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Please don't exceed more than 40 options.
*

Belief systems
Describe your spiritual belief system and/or religious affiliation

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What are your health beliefs? Do you meditate, do yoga, massage, eat well, do chiropractic and or see a medical doctor on a regular basis?

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Please don't exceed more than 40 options.
*
General physical health and relationship to your culture.
​Have you tried or participated in traditional rather than Western medical practices to treat medical or mental health concerns? What have you tried or are currently doing?
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*
Are you currently on any medications? If so what are you taking (over the counter and prescription)?
 
Response is required below.
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Please don't exceed more than 40 options.
*
The reason for your visit:
​Why are you seeking mental health treatment?
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Factors contributing to your concerns:
Are there other factors that you have no control over that help to create your concerns (i.e. divorce in the family, a recent death, natural disaster, economic turndown)