Client Intake Form

Your individual client reference number for on-line anonymity
What things do you enjoy? What do you find interesting? What makes you laugh? Detail some of your achievements
Diagnosed medical conditions/disabilities/mental illness/prescription medication/treatment
Alcohol/tobacco/caffeine/recreational drugs (how long used, how much, how often etc.)? What is your level of physical activity?
What do you need help with? How does the issue affect you and how often?
When did the issue first present itself? What have you done so far to overcome the issue and what was the outcome? What coping strategies work best for you?
What would you like to change in the way you think, feel and behave in respect of the issue and how would you like it to change?
How would you describe your level of motivation to overcome the issue on a scale of 1-10 with 10 being the highest level of motivation?
How will you know when therapy has been successful for you?
Provide any additional information that you feel is relevant to the issue here