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Client Intake Questionnaire

Client Intake Questionnaire

Please fill in the information below and bring it with you to your first session.
Please note: information provided on this form is protected as confidential information.

Personal Information

History

If yes, please list
If yes, please list and provide dates

General and Mental Health Information

If yes, for approximately how long?
If yes, when did you begin experiencing this?
If yes, please describe:
If yes, for how long?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

List Family Member
If yes, what is your current employment situation?
If yes, describe your faith or belief

“Every Man According As He Purposeth In His Heart, So Let Him Give; Not Grudgingly, Or Of Necessity: For God Loveth A Cheerful Giver.”

II Corinthians 9:7