After you have scheduled an appointment with me, please fill out this form to provide information that will help us plan your counseling and other services. All responses will be kept confidential. Thank you for your assistance in making the most of your counseling services.

  • MM slash DD slash YYYY
  • What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can:
  • What is your current occupation? What do you do? How long have you been doing it?
  • Describe your current living situation. Do you live alone, with others. With family, etc…
  • If you are in a relationship, please describe the nature of the relationship and months or years together.
  • What is your level of education? Highest grade/degree and type of degree.
  • Please check any of the following health conditions that apply to you (current or past)
  • Include type of MD, name, and phone number.
  • Have you had any recent surgeries or major medical problems?
  • If you answered "Yes," please describe and give approximate dates:
  • Have you seen a mental health professional before?
  • If you answered "Yes," what is the name of the mental health provider you saw most recently, how long did you see them, and when did you last see them?
  • Have you ever been hospitalized for a psychiatric issue?
  • If you answered "Yes," when and where were you hospitalized and for what reasons?
  • Is there a history of mental illness (depression, anxiety, mood disorders etc.) or substance abuse in your family? If so, please list the family member(s) and type(s) of problems.
  • Do you have (or have you ever had) any of the following? (If so, describe in next section)
  • If you checked any items in the previous question, please describe when they occurred and their nature:
  • Please check any of the following you have experienced in the past six months:
  • Specify all medications and supplements you are presently taking and for what reason.
  • For any prescribed medications listed, please provide the name of the prescriber and their phone number.
  • Do you drink alcohol?
  • If you use alcohol, on an average day when you drink, how many drinks (beer, wine, mixed drink) you you have?
    Please enter a number from 1 to 15.
  • If you use alcohol, during an average week when you drink, how many drinks (beer, wine, mixed drink) you you have?
    Please enter a number from 1 to 50.
  • How many times in the past two months have you had more than five drinks in a day/evening?
    Please enter a number from 0 to 60.
  • Do you currently use any recreational drugs or non-prescribed mood-altering medication, or have you within the past year?
  • If you answered "Yes" above, what have you used within the past year, and how much have you been using it??
  • Have you ever had any of the following problems as a result of alcohol or other drugs?
  • Please describe more about any problems that you checked above - When they happened, any current difficulties still present, etc.
  • Please tell me what you would like to change as a result of counseling, or other goals that you would like to work on.
  • Please tell me anything else that you think it is important for me to know as your therapist, such as scheduling issues, requirements for reporting to your work or someone else, or anything else:

CC BY-ND 4.0 Intake Questionnaire (For new scheduled clients) by Fitzgerald Counseling is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.