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Home
About Eloise Stiglitz, Ph.D.
Services
FAQ
Articles
Forms
Contact

Online Intake Form

Home
Online Intake Form

CLIENT INTAKE FORM
Please provide the following information. Leave blank any question you would rather not answer, or would prefer to discuss with your therapist. Information you provide here is held to the same standards of confidentiality as our therapy.
Name*
Age*
Birthdate*
DD slash MM slash YYYY
Email*
Phone (preferred)*
Can I leave a message here?
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
TREATMENT HISTORY
Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere?
- Yes
- No
Name of professional
Have you had previous psychotherapy?
- Yes
- No
yes, with (previous therapist’s name)
Are you currently taking prescribed psychiatric medication (antidepressants or others)?
- Yes
- No
If yes, please list:
Prescribed by:
For how long?
Do you find them effective?
- Yes
- No
This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, Civil Code and HIPPA Privacy Standards. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/ authorized representative to who it pertains unless other permitted by law.
HEALTH AND SOCIAL INFORMATION
Do you currently have a primary physician?
- Yes
- No
If yes, name
Are you currently seeing more than one medical health specialist?
- Yes
- No
If yes, please list:
When was your last physical?
Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.:)
Are you currently on medication to manage a physical health concern? If yes, please list:
Health problem Medication
What type of exercise do you typically do?
Are you having any sleep problems?
- Yes
- No
If yes, check where applicable:
- Sleeping too little
- Sleeping too much
- Poor quality sleep
- Disturbing dreams
- Can’t fall asleep
- Can’t stay asleep
- other
How frequently do you exercise?
For about how long?
Are you having any difficulty with appetite or eating habits?
- Yes
- No
If yes, check where applicable:
- Eating less
- Eating more
- Bingeing
- Restricting
other
Have you experienced significant weight change in the last 2 months?
- Yes
- No
If yes,
- loss
- gain
How much?
Mental or verbal abuse
- Yes
- No
Do you regularly use alcohol?
- Yes
- No
Typically, how often do you have 4 or more drinks in a 24 hour period?
How often do you engage in recreational drug use?
- daily
- weekly
- monthly
- rarely
- never
Which drugs do you most frequently use?
Do you smoke cigarettes or use other tobacco products?
- Yes
- No
How much and how frequently?
If you have ever smoked, how long ago did you quit?
Have you had suicidal thoughts recently?
- frequently
- sometimes
- rarely
- never
Have you had them in the past?
- frequently
- sometimes
- rarely
- never
Are you currently in a romantic relationship?
- Yes
- No
Sexual orientation
Are you .
- married
- living together
- divorced
- separated
- widowed
If in a relationship, how long have you been together?
On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship?
Are you struggling with issues around a relationship?
- Yes
- No
If yes: Are you
- Dealing with the recent ending of a relationship
- Wanting to develop a romantic relationship
- Struggling with coming out
- Managing a prior relationship, such as in co-parenting
- Managing partner’s declining health or other changes
Managing partner’s declining health or other changes such as
Other
On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship?
Please names and ages of children, if any:
What events in your childhood had a major impact of you? (for example, moves, births, illness or deaths of siblings or parents, school challenges, abuse, financial issues)
Please list names and relationship of people who are your primary social supports:
In the last year, have you experienced any significant life changes? If yes, please explain:
Have you ever experienced any of the following? If yes, please explain….
| Extreme depressed mood |
- Yes
- No
| Dramatic mood swings |
- Yes
- No
| Rapid speech |
- Yes
- No
| Anxiety |
- Yes
- No
| Panic attacks |
- Yes
- No
| Phobias |
- Yes
- No
| Sleep disturbances |
- Yes
- No
| Hallucinations |
- Yes
- No
| Unexplained losses of time |
- Yes
- No
| Sexual or physical abuse |
- Yes
- No
| Alcohol/substance abuse |
- Yes
- No
| Frequent body complaints |
- Yes
- No
| Eating/body image disorder |
- Yes
- No
| Suicidal thoughts |
- Yes
- No
| Repetitive thoughts (e.g. obsessions) |
- Yes
- No
| Repetitive behaviors (e.g. frequent checking, hand washing) |
- Yes
- No
| Homicidal/violent thoughts |
- Yes
- No
| Suicidal attempts |
- Yes
- No
If yes, when?
OCCUPATIONAL AND EDUCATIONAL INFORMATION
Highest level of education
Are you presently in school?
- Yes
- No
If yes, studying with what goal? (degree)
In what field?
where
Are you currently employed?
- Yes
- No
If yes, who is your currently employer/position?
Please list any work-related stressors, if any
If not employed
- seeking employment
- retired
- choose not to work
- gave up looking
This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, Civil Code and HIPPA Privacy Standards. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/ authorized representative to who it pertains unless other permitted by law.
RELIGIOUS/SPIRITUAL INFORMATION
Do you consider yourself to be religious?
- Yes
- No
Do you consider yourself to be spiritual?
- Yes
- No
If religious, what is your faith?
Are you part of a spiritual or religious community?
- Yes
- No
FAMILY MENTAL HEALTH HISTORY
Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following? (circle any that apply and list family member, e.g. sibling parent, uncle, etc.)
| Difficulty | Yes / No | Family member
| Depression |
- Yes
- No
Family member
| Bipolar disorder |
- Yes
- No
Family member
| Anxiety disorder |
- Yes
- No
Family member
| Panic attacks |
- Yes
- No
Family member
| Schizophrenia |
- Yes
- No
Family member
| Alcohol/substance abuse |
- Yes
- No
Family member
| Eating disorders |
- Yes
- No
Family member
| Learning disabilities |
- Yes
- No
Family member
| Trauma history |
- Yes
- No
Family member
| Suicide attempts |
- Yes
- No
Family member
| Chronic illness |
- Yes
- No
Family member
OTHER INFORMATION
What do you consider to be your strengths?
Presently, what are your primary stressors?
What are the effective coping strategies that you have learned?
What are your goals for therapy?
Is there anything else that you think would be helpful for me to know?
This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, Civil Code and HIPPA Privacy Standards. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/ authorized representative to who it pertains unless other permitted by law.
Name
This field is for validation purposes and should be left unchanged.

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Contact Details

contactme@therapistorlando.com

https://www.therapistorlando.com/

Copyright 2018. All rights reserved. Eloise Stiglitz, Ph.D.