802.231.2550 info@innerwell.org
Select Page

Individual Therapy Intake Form


Welcome! This questionnaire provides an opportunity for me to get oriented prior to our first meeting together, and hopefully offers an opportunity for your own self-reflection as well. I encourage you to set aside a little quiet time (10-15 minutes) and you'll need to complete the form in one sitting.

I look forward to reviewing your responses, and meeting with you soon!

Rachel 

Press Enter ↵
1
Your name
2
Preferred first name or nickname, if other than listed above
3
Pronouns
4
Email
5
Cell phone
6
Address
Shift ⇧ + Enter ↵ to make a line break.
7
In a nutshell (one sentence or a few phrases), what's going on that's prompted you to seek out support at this time?
Shift ⇧ + Enter ↵ to make a line break.
8
What are you hoping to get out of our work together? If it were successful, how would you know? (Again, just a few words is fine -- we'll have time to talk about this when we meet.)
Shift ⇧ + Enter ↵ to make a line break.
9
Are you currently working with (or under the care of) any of the following professionals?
  • KeyAIndividual therapist
  • KeyBCouples or family therapist
  • KeyCPsychiatrist
  • KeyDNone of these
Choose as many as you like
10
If you are taking any medications for mood, psychiatric or cognitive issues, please indicate name, dosage, how long you've been taking this medication, what it's for, and the name/role of the prescriber.
11
Please indicate if any of the following are true for you, or have been within the past year:
  • KeyAI have been so depressed or overwhelmed that I couldn't function
  • KeyBI have been worried about or experienced violence at home
  • KeyCI have become so angry that I've been violent with property or people
  • KeyDI have considered ending my life or someone else's
  • KeyEI have engaged in self-harm behaviors
  • KeyFI have been hospitalized for psychiatric reasons
  • KeyGNone of these
Choose as many as you like
12
Please describe your typical use (frequency & amount) of caffeine, alcohol, nicotine, marijuana and any other recreational or self-prescribed drugs. If you have a past history of substance use or are in recovery, please briefly explain.
Shift ⇧ + Enter ↵ to make a line break.
13
Please list any other habits, activities or coping strategies of yours that may be of concern to you or those close to you (e.g., gaming, shopping, porn, gambling, social media, workaholism, etc.), or that are an important part of your history.
Shift ⇧ + Enter ↵ to make a line break.
14
What activities or hobbies in your life help replenish you? How often do you do these?
15
Who are your primary social supports?
16
What do you see as some of your strengths or positive qualities?
17
Is there anything else you'd like me to know at this point? (Please limit this to 2-3 sentences maximum.)
Shift ⇧ + Enter ↵ to make a line break.
18
Sign your name below
0% completed