Intake Form Step 1 of 11 9% General InformationName First Last Date Date Format: 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)AgeOccupationDate of Birth Date Format: MM slash DD slash YYYY Place of BirthHeightWeightDoes your weight fluctuate?YesNoIf yes, by how much?Do you have a family physician?YesNoName of Family PhysicianPhysician Phone NumerBy whom were you referred?Marital StatusSingleLiving togetherEngagedMarriedSeparatedDivorcedWidowedRemarriedHow Many Times?Do you live inHouseRoomApartmentOtherPlease SpecifyWith 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?YesNoPlease ExplainWhat kinds of jobs have you held in the past?Have you been in therapy before?YesNoHave you ever received any professional assistance for your problems?YesNoHave you ever been hospitalized for any psychological/psychiatric problems?YesNoWhen and where?Does any member of your family suffer from an “emotional” or “mental disorder”?YesNoHave you ever attempted suicide?YesNoHas any relative attempted or committed suicide?YesNo Personal And Social History FatherName First Last AgeOccupationHealthIf deceased, give his age at time of deathHow old were you at the time?Cause of deathMotherName First Last AgeOccupationHealthIf deceased, give her age at time of deathHow old were you at the time?Cause of deathSiblingsAge(s) of brother(s)Age(s) of sister(s)Any significant details about siblingsIf 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?YesNoBasically, did you feel loved and respected by your parents?YesNoIf you have a stepparent, give your age when your parent remarriedHas anyone (parents, relatives, friends) ever interfered in your marriage, occupation etc?YesNoPlease describe brieflyScholastic strengthsScholastic weaknessesWhat 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 UpsettingModerately UpsettingVery SevereExtremely SevereIncapacitatingWhen 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 Satisfied1234567How would you rate your overall level of tension during the past month, where 1 is Relaxed, and 7 is Tense1234567 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?YesNoPlease 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 FearsWhat 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?YesNoIf 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 DisagreeDisagreeNeutralAgreeStrongly AgreeI should be good at everything I do.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeWhen I do not know something, I should pretend that I do.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeI should not disclose personal information.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeMy life is controlled by outside forces.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeOther people are happier than I am.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeIt is very important to please other people.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreePlay it safe, don't take any risks.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeI don't deserve to be happy.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeIf I ignore my problems, they will disappear.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeIt is my responsibility to make other people happy.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeI should strive for perfection.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeBasically there are two ways of doing things, the right way and the wrong way.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeI should never be upset.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeI am a victim of circumstances.Strongly DisagreeDisagreeNeutralAgreeStrongly Agree Interpersonal Relationships Friendships Do you make friends easily?YesNoDo you keep them?YesNoDid you date much during High School?YesNoDid you date much during College?YesNoWere you ever bullied or severely teased?YesNoDescribe 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 Anxious12345Do you have one or more friends with whom you feel comfortable sharing your most private thoughts?YesNoMarriage (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 Satisfied12345How do you get along with your partner's friends and family, where 1 is Very Poorly and 5 is Very Well12345How many children do you have?Please give their names and agesDo any of your children present special problems?YesNoPlease 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?YesNoPlease ExplainAny relevant details regarding your first or subsequent sexual experiences?Is your present sex life satisfactory?YesNoPlease 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?YesNoPlease 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?YesNoPlease Explain Biological FactorsDo you currently have any concerns about your physical health?YesNoPlease SpecifyPlease list any medications you are takingDo you eat three well balanced meals each day?YesNoDo you get regular exercise?YesNoWhat 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 periodWere you informed?YesNoDid it come as a shock?YesNoAre you regular?YesNoDurationDo you have pain?YesNoDo your periods affect your moods?YesNoDate of 1st periodCheck any of the following that apply to you:Muscle WeaknessNeverRarelyOccasionallyFrequentlyDailyTranquilizersNeverRarelyOccasionallyFrequentlyDailyDiureticsNeverRarelyOccasionallyFrequentlyDailyDiet PillsNeverRarelyOccasionallyFrequentlyDailyMarijuanaNeverRarelyOccasionallyFrequentlyDailyHormonesNeverRarelyOccasionallyFrequentlyDailySleeping PillsNeverRarelyOccasionallyFrequentlyDailyAsprinNeverRarelyOccasionallyFrequentlyDailyCocaineNeverRarelyOccasionallyFrequentlyDailyPain KillersNeverRarelyOccasionallyFrequentlyDailyNarcoticsNeverRarelyOccasionallyFrequentlyDailyStimulantsNeverRarelyOccasionallyFrequentlyDailyHallucinogens (eg. LSD)NeverRarelyOccasionallyFrequentlyDailyLaxativesNeverRarelyOccasionallyFrequentlyDailyCigarettesNeverRarelyOccasionallyFrequentlyDailyTobacco (specify)NeverRarelyOccasionallyFrequentlyDailyCoffeeNeverRarelyOccasionallyFrequentlyDailyAlcoholNeverRarelyOccasionallyFrequentlyDailyBirth Control PillsNeverRarelyOccasionallyFrequentlyDailyVitaminsNeverRarelyOccasionallyFrequentlyDailyUndereatNeverRarelyOccasionallyFrequentlyDailyOvereatNeverRarelyOccasionallyFrequentlyDailyEat Junk FoodsNeverRarelyOccasionallyFrequentlyDailyDiarrheaNeverRarelyOccasionallyFrequentlyDailyConstipationNeverRarelyOccasionallyFrequentlyDailyGasNeverRarelyOccasionallyFrequentlyDailyIndegestionNeverRarelyOccasionallyFrequentlyDailyNauseaNeverRarelyOccasionallyFrequentlyDailyVomitingNeverRarelyOccasionallyFrequentlyDailyHeartburnNeverRarelyOccasionallyFrequentlyDailyDizzinessNeverRarelyOccasionallyFrequentlyDailyPalpitationsNeverRarelyOccasionallyFrequentlyDailyFatigueNeverRarelyOccasionallyFrequentlyDailyAllergiesNeverRarelyOccasionallyFrequentlyDailyHigh Blood PressureNeverRarelyOccasionallyFrequentlyDailyChest PainNeverRarelyOccasionallyFrequentlyDailyShortness of BreathNeverRarelyOccasionallyFrequentlyDailyInsomniaNeverRarelyOccasionallyFrequentlyDailySleep Too MuchNeverRarelyOccasionallyFrequentlyDailyFitful SleepNeverRarelyOccasionallyFrequentlyDailyEarly Morning AwakeningNeverRarelyOccasionallyFrequentlyDailyEarachesNeverRarelyOccasionallyFrequentlyDailyHeadachesNeverRarelyOccasionallyFrequentlyDailyBackachesNeverRarelyOccasionallyFrequentlyDailyBruise or Bleed EasilyNeverRarelyOccasionallyFrequentlyDailyWeight ProblemsNeverRarelyOccasionallyFrequentlyDailyOtherFrequencyNeverRarelyOccasionallyFrequentlyDailyOtherFrequencyNeverRarelyOccasionallyFrequentlyDailyOtherFrequencyNeverRarelyOccasionallyFrequentlyDaily 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?1234567FEELINGSSome 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?1234567PHYSICAL 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?1234567MENTAL 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?1234567THOUGHTSSome people are very analytical and like to plan things. They like to reason things through. How much of a “thinker” and “planner” are you?1234567INTERPERSONAL 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”.1234567BIOLOGICAL 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?1234567CommentsThis field is for validation purposes and should be left unchanged.