Therapy Intake Form Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY What brings you to therapy at this time?Please describe your history with this condition:What are your goals for counseling?Have you been in therapy before?(Required) Yes No If yes, list the reason and dates:Have you ever been hospitalized for psychiatric reasons or placed on a 5150?(Required) Yes No If yes, list the dates and reasons:Do you self-harm (like "cutting" or "burning")?(Required) Yes No Are you currently experiencing suicidal ideations (thoughts of hurting or killing yourself)?(Required) Yes No In your life, have you experienced trauma?(Required) Yes No Do you drink alcohol?(Required) Yes No If yes, amounts and how often:Do you use recreational drugs?(Required) Yes No If yes, please describe:If you are in a relationship, please describe the nature of the relationship and how long you have been together:Describe your current living situation (do you live alone, with others, with family, etc.):What is your current occupation?Please check any of the following you have experienced in the past six months:(Required) Increased appetite Decreased appetite Trouble concentrating Difficulty sleeping Excessive sleep Low motivation Isolation from others Fatigue/low energy Low self-esteem Depressed mood Tearful or crying spells Anxiety Fear Hopelessness Panic Other (please describe) None What else would you like me to know?