Intake Questionnaire - Individual

Personal Details

Date

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Date of Birth(Required)

Email(Required)

Enter Email Confirm Email

Medicare Number(Required)

Marital Status

Occupation

Have you ever been diagnosed with any of the following: Epilepsy: Depression: Psychosis: Schizophrenia: Bi Polar Disorder: Multiple Personality Disorder; Borderline Personality Disorder, Autistic Spectrum Disorder?(Required)

If Yes, please identify what applies and when it has been diagnosed (year and month)? If no, put full stop or any letter to acknowledge you have read this question.

Any Other Known Significant Mental Health Issues :

If yes, please identify and when diagnosed (month and year).

Current Medications

List any medications you are currently taking.

Section B: Briefly answer the following questions:

1. If you had to pick only one word to describe your life, what would it be?

2. If you had to pick only one word to describe your problems, what would it be?

3. If you had to pick only one word to describe the good times in your life, what would it be?

Please complete the following sentences:

One of the things I feel proud of is

One of the things I feel bad about is

I am happiest when

If I were not afraid to be myself, I would

I get so angry when

I am most saddened by

All my life

Ever since I was a child

One of the ways I could better help myself is

It is hard for me to admit

I am a person who

A mother should

A father should

A true friend should

Significant Memories

Please note down your most significant memory, experience or event from each of the following ages. Include all ages. For sections beyond your current age, write where you imagine yourself to be at that age. If you cannot recall a significant event, don’t worry, just skip the line.

0 to 5 years

5 – 10 years

10 – 15 years

15 – 20 years

20 – 25 years

25 – 30 years

30 – 35 years

35 – 40 years

40 – 45 years

45 – 50 years

50 – 55 years

55 – 60 years

60 – 65 years

65 – 70 years

70+ years

Please give short answers to the following questions:

What motivates you?

What makes you happy?

Which behaviors do you believe are getting in the way of your happiness?

What would you like to start doing more of?

What would you like to stop doing?

C) Presenting Issues or Concerns

Please answer the following question in only two or three sentences

Issue 1 – For what particular issue/problem – issues/problems are you seeking help?

Please rate on a scale from 1-10 how strongly you believe this issue is affecting you day to day (check box)

In your opinion, what could be causing this problem/issue?

Issue 2 – For what particular issue/problem – issues/problems are you seeking help?

Please rate on a scale from 1-10 how strongly you believe this issue is affecting you day to day (check box)

In your opinion, what could be causing this problem/issue?

Issue 3 – For what particular issue/problem – issues/problems are you seeking help?

Please rate on a scale from 1-10 how strongly you believe this issue is affecting you day to day (check box)

In your opinion, what could be causing this problem/issue?

Final Question

When you address or make the changes to the issues or concerns, how would this positively affect your life (list 4 or more changes)?

Name

This field is for validation purposes and should be left unchanged.

TFD Services

Intake Questionnaire – Individual

Dear Client,