Intake Form

Intake Form: Linda J. Cooke, LCSW
Please provide the following information as accurately as possible. Please note: information you submit here is protected as confidential information.
Full Name

First Name Middle Initial Last Name
Name of parent/guardian (if under 18 years)

First Name Middle Initial Last Name
Birth Date

- Month - Day Year
Gender

Female Male
Marital Status

Never Married Domestic Partnership Married Separated Divorced Widowed
Please list any childen and their age[s]
Email address

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

- Area Code Phone Number
May we leave a message?

Yes No
Cell/Other phone

- Area Code Phone Number
May we leave a message?

Yes No
E-mail
*Please note: Email correspondence is not considered to be a confidential medium of communication.
May we email you?

Yes No
Referred by (if any)
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

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Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

No Yes (please indicate therapist/practitioner below)
Therapist/practitioner name
Are you currently taking any prescription medication?

No Yes (please list medications below)
Prescription medication taken
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
1. How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very good
Please list any specific health problems you are currently experiencing
2. How would your rate your current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very good
Please list any specific sleep problems you are currently experiencing
3. How many times per week do you exercise?
What types of exercise do you participate in?
4. Please list any difficulties you experience with your appetite or eating patterns
5. Are you currently experiencing overwhelming sadness, grief, or depression?

No Yes
If yes, for approximately how long?
6. Are you currently experiencing anxiety, panic attacks, or have any phobias?

No Yes
If yes, when did you begin experiencing this?
7. Are you currently experiencing any chronic pain?

No Yes
If yes, please describe
8. Do you drink alcohol more than once per week?

No Yes
9. How often do you engage in recreational drug use?

Daily Weekly Monthly Infrequently Never
10. Are you currently in a romantic relationship?

No Yes
If yes, for how long?
On a scale of 1-10, how would you rate your satisfaction with your relationship?
11. What significant life changes or stressful events have you experienced recently?
FAMILY MENTAL HEALTH HISTORY
In the section below identify if there is a family history of any of the following. If yes, indicate the family member's relationship to you (father, grandmother, uncle, etc.).
Alcohol/Substance misuse
Anxiety
Depression
Domestic violence
Eating disorders
Obesity
Obsessive compulsive behavior
Schizophrenia
Suicide attempts
ADDITIONAL INFORMATION
1. Are you currently employed?

No Yes
If yes, describe your current empolyment situation
Do you enjoy your work? Is there anything stressful about your current work?
2. Do you consider yourself to be spiritual or religious?

Yes No
If yes, describe your faith or belief
3. What do you consider to be some of your strengths?
4. What do you consider to be some of your weaknesses?
5. What would you like to accomplish out of your time in therapy?
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Intake Form: Linda J. Cooke, LCSW

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

FAMILY MENTAL HEALTH HISTORY

ADDITIONAL INFORMATION