Therapy client intake form Step 1/6: Personal Details: Leave this field blank Full Name: Date of Birth: Gender: Address: Phone Number: Email: Occupation: Relationship Status: Single Married Partner Separated Divorced Widowed Emergency Contact (Name, Relationship, Phone): Have you previously received any form of psychological therapy? Yes Please provide details (e.g., duration, reasons for therapy, outcomes): No If yes, please provide details (e.g., duration, reasons for therapy, outcomes): Have you ever been diagnosed with a mental health condition? Yes No If yes, please list the condition(s), date of diagnosis, and any treatment received: Are you currently taking any medications? Yes No If yes, please list the medications and their purposes: Have you experienced any hospitalisations or medical treatments related to mental health? Yes No If yes, please describe: Do you have any physical health issues that may affect your mental health (e.g., chronic pain, illness)? Yes No If yes, please explain: What brings you to therapy? How long have you been experiencing these concerns? On a scale of 1-10, how much do these concerns impact your daily life? 5 Are there any specific events that have triggered or worsened your concerns? Do you currently experience any of the following? Anxiety Depression Panic Attacks Sleep Disturbances Mood Swings Thoughts of Self-Harm Suicidal Thoughts Substance Abuse Alcohol/Drugs etc Chronic Stress Relationship Difficulties Other Please specify below If other, please explain: Do you have a support system in place? If yes, please explain below Yes No If yes, who is part of your support system (e.g., family, friends, community groups)? How do you typically manage stress? Describe your current sleep habits: Describe your current eating habits: How often do you exercise or engage in physical activity? Do you engage in any mindfulness or relaxation practices (e.g., meditation, yoga)? If yes, please specify below Yes No If yes, please specify What do you hope to achieve through therapy? What would success in therapy look and feel like to you? Is there anything else you would like your therapist to know about you or your situation? Do you understand that therapy sessions are confidential, except in cases where there is a risk of harm to yourself or others? Yes No Do you consent to receive therapy services? Yes No Are you 100% committed to accepting therapy, practising any techniques taught and completing any tasks set? Yes No Thank you for taking the time to complete this intake questionnaire. Your responses will help guide your therapy sessions and ensure that your needs are met. Please Sign Here: Start drawing Clear Done Start over Continue
