Client Intake Form
Full Name
First Name
Last Name
Name of parent or guardian if under 18 years
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date Picker Icon
Marital Status
Married
Single (never married)
Divorced
Separated
Widowed
Domestic Partnership
Spouse Name
Please list any children/age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
-
Area Code
Phone Number
Can we leave a message?
yes
No
E-mail
Can we email you?
yes
No
How did you hear about Stewart Family Counseling?
How did you hear about Stewart Family Counseling?
SFC Website
Psychology Today
Friend/Dr Referral
Family Member
Insurance Directory
Therapy Next
Network Therapy
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Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
yes
no
If yes, previous therapist/practitioner
Are you currently taking any prescription medication?
yes
no
If yes, please list
Have you been prescribed psychiatric medication?
yes
no
If yes, please list and provide dates prescribed and dosage
General Health
How would you rate your current physical health?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any current health problems
Date of last physical
How many times per week do you exercise?
How would you rate your current sleep habits?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Do any of these struggles apply to you?
Anxiety/Worried
Depression
Sadness
Grief
Addictions
Sexual issues
Suicidal Thoughts
Anger
Obsessions or Compulsive Behavior
Other
Do you drink alcohol more than once a week?
yes
no
How often do you engage in recreational drug use?
Daily
Weekly
Monthly
Infrequently
Never
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Are you currently in a committed relationship?
yes
no
If yes, for how long?
On a scale from 1-10, how would you rate your relationship?
Are you currently employed
yes
no
Occupation
Do you enjoy your work? Anything stressful about it?
Please list any significant family history events or issues (i.e. parental divorce, substance abuse, illnesses, child abuse, etc).
Do you consider yourself spiritual or religious?
yes
no
If so, please describe your faith or beliefs
What are some of your strengths?
What do you consider are your weaknesses?
What significant life events may be a focal point in therapy?
What would you like to accomplish out of your time in therapy?
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