ABC’d Therapy & Consulting, LLC
6842 University Avenue, Ste B
Windsor Heights, IA 50324

Intake Questionnaire


Demographic Information

Name:  
Preferred Name:  
Preferred Pronouns:  
Date of Birth:  
Gender:  
Race/Ethnicity:  
Email Address:  
  Yes, it is ok to receive emails
  No, do not email me
Home Phone:  
  Yes, it is ok to leave a message
  No, do not leave a message
Cell Phone:  
  Yes, it is ok to leave a message
  No, do not leave a message
Street Address:  
I authorize the following people to receive information about appointments:
Emergency Contact (Name, relationship, contact information): Occupation and Employer:
Household Income:  
Who referred you or how did you hear about ABC'd Therapy & Consulting, LLC?

Treatment Information

What is your reason for seeking counseling at this time?
Have you previously seen a therapist? If Yes, enter previous therapist name(s) and describe treatment:
Have you ever been a victim of domestic violence?
  Yes
  No
Have you ever suffered abuse or violence of any kind?
  No, I have not
  Unsure
  Neglect
  Physical Abuse
  Verbal or Emotional Abuse
  Sexual Abuse or Assault
  Spiritual Abuse
  Other:

Current Symptoms

Check any that have occurred withing the past two weeks:
  Anxiety
  Appetite Issues
  Avoidance
  Blaming yourself for things
  Body aches or pains
  Crying Spells
  Depression
  Excessive Energy
  Fatigue
  Feeling Lonely
  Feeling Fearful
  Feeling tense or keyed up
  Feelings of worthlessness
  Frequent arguments
  Feeling caught or trapped
  Feeling hopeless about the future
  Guilt
  Hallucinations
  Headaches
  Hearing voices
  Internal Nervousness or shakiness
  Impulsivity
  Irritability
  Libido Changes
  Loss of Interest
  Never feeling close to anyone
  Panic Attacks
  Racing Thoughts
  Risky Activity
  Shouting or throwing things
  Sleep Changes
  Suspiciousness
  The idea that somebody else controls your thoughts
  Thoughts of ending your life
  Trouble concentrating
  Urge to break or smash things

Medical History

Exercise Frequency:  
Exercise Type:  
Allergies:  
What medications are you currently using?
Previous diagnoses/mental health treatment:
Previously treated by:  
Previous medications:  
Dates treated:  
Previous medical conditions:
Previous surgeries:

Family History

Were you adopted? If yes, at what age?
How is your relationship with your mother? How is your relationship with your father? Siblings and their ages:
Are your parents married?  
Did your parents divorce? If yes, how old were you?
Did your parents remarry? If yes, how old were you?
Who raised you?  
Where did you grow up?  
Family member medical conditions: Family member mental conditions:

Present Situation

Work: Are you married? If yes, specify length of time married: Are you divorced? If yes, specify year of divorce: Prior marriages? If yes, how many? What is your sexual orientation?
Are you sexually active?  
How is your relationship with your partner?  
Do you have child(ren)? If yes, how is your relationship with your child(ren)?
Are you a member of a religious/spiritual group?  
Have you ever been arrested? If yes, when and why?

Have you ever tried the following?

Check all that apply:
  Alcohol
  Tobacco
  Marijuana
  Hallucinogens (LSD)
  Heroin
  Methamphetamines
  Cocaine
  Stimulants (Pills)
  Ecstasy
  Methadone
  Tranquilizers
  Pain Killers
If yes to any, list frequency/dates of use: Have you ever been treated for drug/alcohol abuse? If yes, when?
Do you smoke cigarettes? If yes, how many per day?  
Do you drink caffeinated beverages? If yes, how many per day?  
Have you ever abused prescription medication? If yes, which ones?

Additional

Anything else you want the therapist to know?