Intake form Individual Therapy

Name and surname

Address

Postal code

Town/City

Telephone number

Date of birth

Marital status

Place of work / occupation

GPs name and address

Please could you describe your reason for therapy?

Please could you describe the cause(s) of the problem(s)?

Please could you write down which people in your network are important to you?

How would you describe the seriousness of the problem(s)?

Mild
Serious
Very serious

What would you like to achieve in the therapy?

Are there any other problems (i.e. work, relationships, friends, finances)?

Have there been traumatic incidents which are related to your problem(s)?

Do you use alcohol? If so, how much/ how often?

Do you use drugs? If so, how much/ how often

Do you have physical or emotional problems? If so, please give a short description

How long have you had these problems?

Have you seen any of the following?

GP
Psychiatrist
Another specialist

Have you visited a therapist? If so who and how long?

Have you been diagnosed?

Yes
No

By whom?

MD
Psychiatrist
Psychologist
Another specialist

Which diagnosis has been made?

Are you currently undergoing medical, psychological or psychiatric treatment?

Yes
No

Where are you undergoing medical, psychological or psychiatric treatment?

Do you use medicines?

Yes
No

Which medicines?

Do you give me permission to ask your GP for information?

Yes
No

Do you give me permission to inform your GP about the start and completion of the therapy?

Yes
No

Do you have children from your current relationship?

Yes
No

Do you have children from a previous relationship?

Yes
No

Name first child

Are you the biological parent?

Yes
No

Male or Female?

Male
Female

Age?

Name second child

Are you the biological parent?

Yes
No

Male or Female?

Male
Female

Age?

Name third child

Are you the biological parent?

Yes
No

Male or Female?

Male
Female

Age?

Do any of your children suffer from problems?

Yes
No

Which problems?

Is your father still alive?

Yes
No

What is his age?

At what age is he deceased?

What is/was your father’s occupation?

What is/was your mother’s occupation?

How many brothers do you have?

How many sisters do you have?

Further information about your family that could be important for your therapy

Intake Form Individual Therapy