Confidential Client Intake

Step 1 of 2

  • MM slash DD slash YYYY
  • PRESENTING PROBLEM

  • THE FOLLOWING INFORMATION IS VERY IMPORTANT WHEN DESIGNING AN APPROPRIATE TREATMENT PLAN. THE MORE ANSWERS YOU PROVIDE PRIOR TO SESSION, THE MORE TIME WILL BE AVAILABLE DURING SESSION TO ADDRESS YOUR PRESENTING PROBLEM.

  • SOCIAL CULTURAL BACKGROUND

  • ACADEMIC / WORK BACKGROUND

  • RELATIONAL / SUPPORT HISTORY

  • FAMILY BACKGROUND

  • PHYSICAL HEALTH

  • MENTAL HEALTH HISTORY

  • ALCOHOL AND OTHER DRUG USE