Intake Questionnaire

What brings you to therapy at this time? Is there something specific, such as a particular event? Be as detailed as you can.
What are your goals for therapy?
How would you like to be different as a result of therapy?
Question 4
Have you seen a mental health professional before?
Have you been give a diagnosis before? Please indicate.
Specify all medications and supplements you are presently taking and for what reason.
If taking prescription medication, who is your prescriber? Please indicate if they are a primary care physician or a psychiatric prescriber. Include their name and phone number.
Question 8
Do you drink alcohol?
Question 9
Do you use recreational drugs?
Question 10
Do you have suicidal thoughts?
Question 11
Have you ever attempted suicide?
Question 12
Do you have thoughts or urges to harm others?
Question 13
Have you ever been hospitalized for a psychiatric issue?
Question 14
Is there a history of mental illness in your family?
If you are in a relationship, please describe the nature of the relationship and months or years together.
Describe your current living situation. Do you live alone, with others? With family, etc.
What is your level of education? Highest grade/degree and type of degree.
What is your current occupation? What do you do? How long have you been doing it?
Question 19
Please check any of the following that you have experienced in the past six months?
When did these symptoms begin?
Is there anything that has helped make the symptoms/problems better?
Is there anything that has made the symptoms/problems worse?
Question 23
Please check any of the following that apply.
Please list any significant health concerns, illnesses, injuries, or surgeries you have experienced.
On overage, how much sleep do you get daily? Describe any current or past sleep problems.
What do you like about yourself? What are your strengths?
What do you dislike about yourself? What are your weaknesses?
What are your special interests and hobbies?
Please describe any current or past problems with weight and/or eating.
Question 30
Have you experienced the following, either currently or in the past?
Question 31
Has anyone in your family experienced the following, either currently or in the past?
What else would you like me to know?

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You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.  You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059.

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