Intake Form Step 1 of 11 9% General InformationName First Last Date MM slash DD slash YYYY Email (Please enter a secure email to recieve a copy of your intake form) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (Day)Phone (Night)AgeOccupation Date of Birth MM slash DD slash YYYY Place of Birth Height Weight Does your weight fluctuate? Yes No If yes, by how much? Do you have a family physician? Yes No Name of Family Physician Physician Phone NumerBy whom were you referred? Marital Status Single Living together Engaged Married Separated Divorced Widowed Remarried How Many Times? Do you live in House Room Apartment Other Please Specify With whom do you live? (check all that apply) Parents Spouse Roommates Child(ren) Friend(s) Others Please Specify: Describe your occupationDoes your present work satisfy you? Yes No Please ExplainWhat kinds of jobs have you held in the past?Have you been in therapy before? Yes No Have you ever received any professional assistance for your problems? Yes No Have you ever been hospitalized for any psychological/psychiatric problems? Yes No When and where?Does any member of your family suffer from an “emotional” or “mental disorder”? Yes No Have you ever attempted suicide? Yes No Has any relative attempted or committed suicide? Yes No Personal And Social History FatherName First Last Age Occupation Health If deceased, give his age at time of death How old were you at the time? Cause of death MotherName First Last Age Occupation Health If deceased, give her age at time of death How old were you at the time? Cause of death SiblingsAge(s) of brother(s) Age(s) of sister(s) Any significant details about siblings If you were not brought up by your parents, who raised you and between what years?Give a description of your father's (or father substitute’s) personality and his attitude towards youGive a description of your mother's (or mother substitute’s) personality and his attitude towards youIn what ways were you disciplined or punished by your parents?Give an impression of your home atmosphere (ie the home in which you grew up). Mention state of compatibility between parents and between children.Were you able to confide in your parents? Yes No Basically, did you feel loved and respected by your parents? Yes No If you have a stepparent, give your age when your parent remarried Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation etc? Yes No Please describe brieflyScholastic strengths Scholastic weaknesses What was the last grade completed (or highest degree)? Check any of the following that applied during your childhood/adolescence Happy Childhood Unhappy Childhood Emotional/behavior problem Legal Trouble Death in Family Medical Problems Ignored Not Enough Friends School Problems Financial Problems Strong Religious Convictions Drug Use Used Alcohol Severely Punished Sexually Abused Severely Bullied Eating Disorder Other Other Description Of Presenting ProblemsState in your own words the nature of your main problemsOn the scale below, please estimate the severity of your problem(s) Mildly Upsetting Moderately Upsetting Very Severe Extremely Severe Incapacitating When did your problems begin?What seems to worsen your problems?What have you tried that has been helpful?How satisfied are you with your life as a whole these days, where 1 is Not at all Satisfied, and 7 is Very Satisfied 1 2 3 4 5 6 7 How would you rate your overall level of tension during the past month, where 1 is Relaxed, and 7 is Tense 1 2 3 4 5 6 7 Modality Analysis Of Current Problems The following section is designed to help you describe your current problems in greater detail and to identify problems that might otherwise go unnoticed. This will enable us to design a comprehensive treatment program and tailor it to your specific needs. The following section is organized according to the seven modalities of: Behaviors, Physical Sensations, Images, Thoughts, Interpersonal Relationships, and Biological Factors. BehaviorsCheck any of the following behaviors that often apply to you Overeat Take Drugs Unassertive Odd Behavior Drink Too Much Work Too Hard Procrastination Impulsive Reactions Loss of Control Suicidal Attempts Compulsions Smoke Withdrawal Nervous Tics Concentration Issues Sleep Disturbance Phobic Avoidance Overspending Can't Keep a Job Insomnia Risk Taking Lazy Eating Problems Aggression Crying Temper Outbursts Others OthersWhat are some special talents or skills you feel proud of?What would you like to start doing?What would you like to stop doing?How is your free time spent?What kind of hobbies or leisure activities do you find relaxing?Do you have trouble relaxing or enjoying weekends and vacations? Yes No Please explainIf you could have any two wishes, what would they be? FeelingsCheck any of the following feelings that apply to you Angry Annoyed Sad Depressed Anxious Fearful Panicky Energetic Envious Guilty Happy Conflicted Shameful Regretful Hopeless Hopeful Helpless Relaxed Jealous Unhappy Bored Restless Lonely Contented Excited Optimistic Tense Others Please Detail OthersList your Five Main Fears What are some positive feelings you've experienced recently?When are you most likely to lose control of your feelings?Describe any situations that make you feel calm and relaxed Physical SensationsCheck any of the following physical sensations that often apply to you Abdominal Pain Pain with Urination Menstrual Issues Headaches Dizziness Palpitations Muscle Spasms Tension Sexual Disturbance Hard to Relax Bowel Problems Tingling Numbness Stomach Trouble Tics Fatigue Twitches Back Pain Tremors Fainting Spells Hearing Things Watery Eyes Flushing Nausea Skin Problems Dry Mouth Itching/Burning Skin Chest Pains Rapid Heart Beat Dislike Touching Blackouts Sweating Seeing Things Hearing Problems Others Please Detail Others Images Check any of the following that apply to you: I picture myself Being Happy Being Hurt Not Coping Succeeding Losing Control Being Followed Being Talked About Being Aggressive Being Helpless Hurting Others Being in Charge Failing Being Trapped Being Laughed At Being Promiscuous Others Please Detail OthersI have Pleasant Sexual Images Unpleasant Childhood Images Negative Body Image Unpleasant Sexual Images Lonely Images Seduction Images Images of Being Loved Others Please Details OthersDescribe a very pleasant image, mental picture, or fantasyDescribe a very unpleasant image, mental picture, or fantasyDescribe your image of a completely “safe place”Describe any persistent or disturbing images that interfere with your daily functioningHow often do you have nightmares? ThoughtsCheck each of the following that you might use to describe yourself Intelligent Confident Worthwhile Ambitious Sensitive Loyal Trustworthy Full of Regrets A Nobody Useless Evil Crazy Degenerate Considerate Deviant Unattractive Unlovable Inadequate Confused Ugly Stupid Naive Honest Incompetent Awful Thought Conflicted Can't Focus Forgetful Attractive Indecisive Suicidal Perservereing Funny Hard Working Undesireable Lazy Untrustworthy Dishonest Others OthersWhat do you consider to be your craziest thought or idea?Are you bothered by thoughts that occur over and over again? Yes No If yes, what are these thoughtsWhat worries do you have that may negatively affect your mood or behavior?On each of the following items, please circle the number that most accurately reflects your opinions.I should not make mistakes. Strongly Disagree Disagree Neutral Agree Strongly Agree I should be good at everything I do. Strongly Disagree Disagree Neutral Agree Strongly Agree When I do not know something, I should pretend that I do. Strongly Disagree Disagree Neutral Agree Strongly Agree I should not disclose personal information. Strongly Disagree Disagree Neutral Agree Strongly Agree My life is controlled by outside forces. Strongly Disagree Disagree Neutral Agree Strongly Agree Other people are happier than I am. Strongly Disagree Disagree Neutral Agree Strongly Agree It is very important to please other people. Strongly Disagree Disagree Neutral Agree Strongly Agree Play it safe, don't take any risks. Strongly Disagree Disagree Neutral Agree Strongly Agree I don't deserve to be happy. Strongly Disagree Disagree Neutral Agree Strongly Agree If I ignore my problems, they will disappear. Strongly Disagree Disagree Neutral Agree Strongly Agree It is my responsibility to make other people happy. Strongly Disagree Disagree Neutral Agree Strongly Agree I should strive for perfection. Strongly Disagree Disagree Neutral Agree Strongly Agree Basically there are two ways of doing things, the right way and the wrong way. Strongly Disagree Disagree Neutral Agree Strongly Agree I should never be upset. Strongly Disagree Disagree Neutral Agree Strongly Agree I am a victim of circumstances. Strongly Disagree Disagree Neutral Agree Strongly Agree Interpersonal Relationships Friendships Do you make friends easily? Yes No Do you keep them? Yes No Did you date much during High School? Yes No Did you date much during College? Yes No Were you ever bullied or severely teased? Yes No Describe any relationship that gives you JoyDescribe any relationship that gives you GriefRate the degree to which you generally feel relaxed and comfortable in social situations, where 1 is Relaxed and 5 is Anxious 1 2 3 4 5 Do you have one or more friends with whom you feel comfortable sharing your most private thoughts? Yes No Marriage (or a committed relationship)How long did you know your spouse before your engagement? How long were you engaged before you got married? How long have you been married? What is your spouse's age? His/her occupation? Describe your spouse's personality?What do you like most about your spouse?What do you like least about your spouse?What factors detract from your marital satisfaction?On the scale below, please indicate how satisfied you are with your marriage, where 1 is Dissatisfied and 5 is Satisfied 1 2 3 4 5 How do you get along with your partner's friends and family, where 1 is Very Poorly and 5 is Very Well 1 2 3 4 5 How many children do you have? Please give their names and agesDo any of your children present special problems? Yes No Please DescribeAny significant details about a previous marriage?Sexual RelationshipsDescribe your parent's attitude towards sex. Was sex discussed in your home?When and how did you derive your first knowledge of sex?When did you first become aware of your own sexual impulses?Have you ever experienced any guilt or anxiety arising out of sex or masturbation? Yes No Please ExplainAny relevant details regarding your first or subsequent sexual experiences?Is your present sex life satisfactory? Yes No Please ExplainPlease provide information about any significant homosexual reactions or relationshipsPlease note any sexual concerns not discussed aboveOther RelationshipsAre there any problems in your relationships with people at work? Yes No Please describePlease complete the following:One of the ways people hurt me isI could shock you byMy spouse/boyfriend/girlfriend would describe me asMy best friend thinks I amPeople who dislike meAre you currently troubled by any past rejections or loss of a love relationship? Yes No Please Explain Biological FactorsDo you currently have any concerns about your physical health? Yes No Please SpecifyPlease list any medications you are takingDo you eat three well balanced meals each day? Yes No Do you get regular exercise? Yes No What type and how often?Please list any significant medical problems that apply to you or members of your familyPlease describe any surgery you have had (give dates)Please describe any physical handicap(s) you haveMenstrual HistoryAge at first period Were you informed? Yes No Did it come as a shock? Yes No Are you regular? Yes No DurationDo you have pain? Yes No Do your periods affect your moods? Yes No Date of 1st period Check any of the following that apply to you:Muscle Weakness Never Rarely Occasionally Frequently Daily Tranquilizers Never Rarely Occasionally Frequently Daily Diuretics Never Rarely Occasionally Frequently Daily Diet Pills Never Rarely Occasionally Frequently Daily Marijuana Never Rarely Occasionally Frequently Daily Hormones Never Rarely Occasionally Frequently Daily Sleeping Pills Never Rarely Occasionally Frequently Daily Asprin Never Rarely Occasionally Frequently Daily Cocaine Never Rarely Occasionally Frequently Daily Pain Killers Never Rarely Occasionally Frequently Daily Narcotics Never Rarely Occasionally Frequently Daily Stimulants Never Rarely Occasionally Frequently Daily Hallucinogens (eg. LSD) Never Rarely Occasionally Frequently Daily Laxatives Never Rarely Occasionally Frequently Daily Cigarettes Never Rarely Occasionally Frequently Daily Tobacco (specify) Never Rarely Occasionally Frequently Daily Coffee Never Rarely Occasionally Frequently Daily Alcohol Never Rarely Occasionally Frequently Daily Birth Control Pills Never Rarely Occasionally Frequently Daily Vitamins Never Rarely Occasionally Frequently Daily Undereat Never Rarely Occasionally Frequently Daily Overeat Never Rarely Occasionally Frequently Daily Eat Junk Foods Never Rarely Occasionally Frequently Daily Diarrhea Never Rarely Occasionally Frequently Daily Constipation Never Rarely Occasionally Frequently Daily Gas Never Rarely Occasionally Frequently Daily Indegestion Never Rarely Occasionally Frequently Daily Nausea Never Rarely Occasionally Frequently Daily Vomiting Never Rarely Occasionally Frequently Daily Heartburn Never Rarely Occasionally Frequently Daily Dizziness Never Rarely Occasionally Frequently Daily Palpitations Never Rarely Occasionally Frequently Daily Fatigue Never Rarely Occasionally Frequently Daily Allergies Never Rarely Occasionally Frequently Daily High Blood Pressure Never Rarely Occasionally Frequently Daily Chest Pain Never Rarely Occasionally Frequently Daily Shortness of Breath Never Rarely Occasionally Frequently Daily Insomnia Never Rarely Occasionally Frequently Daily Sleep Too Much Never Rarely Occasionally Frequently Daily Fitful Sleep Never Rarely Occasionally Frequently Daily Early Morning Awakening Never Rarely Occasionally Frequently Daily Earaches Never Rarely Occasionally Frequently Daily Headaches Never Rarely Occasionally Frequently Daily Backaches Never Rarely Occasionally Frequently Daily Bruise or Bleed Easily Never Rarely Occasionally Frequently Daily Weight Problems Never Rarely Occasionally Frequently Daily Other Frequency Never Rarely Occasionally Frequently Daily Other Frequency Never Rarely Occasionally Frequently Daily Other Frequency Never Rarely Occasionally Frequently Daily Structural Profile Directions: Rate yourself on the following dimensions on a seven-point scale with “1” being the lowest and “7” being the highest.BEHAVIORSSome people may be described as “do-ers” - they are action oriented, like to busy themselves, get things done, take on various projects. How much of a “do-er” are you? 1 2 3 4 5 6 7 FEELINGSSome people are very emotional and may or may not express it. How emotional are you? How deeply do you feel things? How passionate are you? 1 2 3 4 5 6 7 PHYSICAL SENSATIONSSome people attach a lot of value to sensory experiences, such as sex, food, music, art, and other “sensory delights”. Others are very much aware of minor aches, pains, and discomforts. How “tuned into” your sensations are you? 1 2 3 4 5 6 7 MENTAL IMAGESHow much fantasy or daydreaming do you engage in? This is separate from thinking or planning. This is “thinking in pictures”, visualizing real or imagined experiences, letting your mind roam. How much are you into imagery? 1 2 3 4 5 6 7 THOUGHTSSome people are very analytical and like to plan things. They like to reason things through. How much of a “thinker” and “planner” are you? 1 2 3 4 5 6 7 INTERPERSONAL RELATIONSHIPSHow important are other people to you? This is your self rating as a social being. How important are close friendships to you, the tendency to gravitate towards people, the desire for intimacy? The opposite of this is being a “loner”. 1 2 3 4 5 6 7 BIOLOGICAL FACTORSAre you healthy and health conscious? Do you avoid bad habits like smoking, too much alcohol, drinking a lot of coffee, overeating etc? Do you exercise regularly, get enough sleep, avoid junk foods, and generally take care of your body? 1 2 3 4 5 6 7 PhoneThis field is for validation purposes and should be left unchanged. Δ
