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Mental and Emotional Wellness Client Intake Form

Client Information

First Name

Last Name

Date of Birth

Gender

Street Address

City/Suburb

State/Province

Postal/Zip Code

Phone Number

Email Address

Emergency Contact

First Name

Last Name

Phone Number

Relationship

Physician

Primary Care

Phone Number

Reason for Seeking Services

Please describe the primary reason(s) you are seeking mental and emotional wellness services.

What are your current concerns or challenges?

How long have you been experiencing these concerns?

Have you received mental health services in the past?

If yes, please provide details.

Are you currently taking any medications?

If yes, please list them.

Do you have any known allergies?

Are you currently experiencing any physical health issues?

Mental and Emotional Health History

Have you ever been diagnosed with a mental health condition?

If yes, please list them.

Have you ever experienced

Depression

Anxiety

Panic attacks

Trauma/PTSD

Substance use issues

Eating disorders

Relationship problems

Grief/loss

Sleep disturbances

Other:

Have you ever had suicidal thoughts or attempts?

If yes, please provide details.

Have you ever had thoughts of harming others?

If yes, please provide details.

Do you have any family history of mental health conditions?

Lifestyle and Support Systems

What is your current living situation?

Describe your current support system (family, friends, etc.).

What are your current work/school/daily activities?

Do you engage in any regular exercise?

Describe your typical sleep patterns.

Describe your typical eating habits.

Do you use alcohol, tobacco, or other substances?

If yes, please provide details.

What are your hobbies or interests?

What are your strengths?

Service Options and Suitability

Individual Therapy

Description: One-on-one sessions with a therapist to address personal concerns, develop coping skills, and promote emotional well-being.

 

Suitability:

 

Do you prefer a private and confidential setting?

Do you have specific personal issues you wish to address individually?

Do you believe you would benefit from personalized attention?

Specialized individual therapy options:

Trauma informed therapy

CBT (Cognitive Behavioral Therapy)

DBT (Dialectical Behavior Therapy)

ACT (Acceptance and Commitment Therapy)

Grief Counseling

Relationship counseling

Group Therapy

Description: Therapy sessions with a small group of individuals who share similar concerns, providing peer support and shared learning.

 

Suitability:

 

Are you open to sharing your experiences with others?

Do you believe you would benefit from peer support and feedback?

Are you comfortable in a group setting?

Do you struggle with social isolation?

Group Therapy Options:

Anxiety Management Group

Depression Support Group

Grief Support Group

Trauma Recovery Group

Relationship Skills Group

Mindfulness and Stress Reduction Group

Substance Abuse recovery group

Couples/Family Therapy

Description: Therapy sessions involving couples or families to address relationship issues, improve communication, and resolve conflicts.

 

Suitability:

 

Are you seeking to improve communication and resolve conflicts within your relationship or family?

Are you and your partner/family members willing to participate in joint sessions?

Are you looking to rebuild trust?

Couple/Family Therapy:

Emotionally Focused Therapy (EFT)

The Gottman Method

Functional Family Therapy (FFT)

Cognitive Behavioral Therapy (CBT)

Narrative Therapy

Solution-Focused Brief Therapy

Strategic Family Therapy

Behavioral Couples Therapy (BCT)

Wellness Workshops/Classes

Description: Educational sessions focused on specific wellness topics, such as stress management, mindfulness, or emotional regulation.

 

Suitability:

 

Are you interested in learning new coping skills and wellness strategies?

Do you prefer a structured learning environment?

Are you looking to improve your overall wellbeing?

Wellness Workshops Options:

Mindfulness and Meditation

Stress Management Techniques

Resilience Building

Healthy Habits

Workplace Mental Health

Mental Health Awareness

Accidental Counsellor Training

Client Questions Regarding Service Suitability

Which of the above service options are you most interested in?

Do you have any concerns or questions about the services offered?

Are there any specific goals you would like to achieve through therapy or wellness services?

Are there any factors that may affect your ability to attend sessions regularly?

Do you have any scheduling preferences?

Do you have any financial concerns related to these services?

Consent and Confidentiality

I understand that all information shared during therapy sessions will be kept confidential, except in cases where I pose a danger to myself or others, or as required by law.

I consent to participate in the chosen mental and emotional wellness services.

I have read and understand the agency's confidentiality policy.

Client Signature

Client Intake Form Insights

Please remove this client form insights section before publishing.


Important Notes:

  • This form is intended to gather initial information and does not constitute a diagnosis.
  • The information provided will be used to determine the most appropriate services for the client.
  • The therapist/intake specialist will discuss the client's needs and goals in more detail during the initial consultation.
  • It is crucial to adapt this form to comply with all local and national privacy laws.
  • This form is a template, and may need to be adjusted to suit the specific needs of your practice.

This form is designed to be comprehensive, covering a wide range of aspects crucial for establishing a strong therapeutic relationship and tailoring services effectively. Here's a breakdown of its key strengths and insights:


Strengths and Key Insights:

Holistic Approach:

  • It goes beyond just mental health symptoms, encompassing lifestyle, support systems, and physical health. This holistic view allows for a more complete understanding of the client's overall well-being.
  • By considering factors like sleep, eating habits, and substance use, the form recognizes the interconnectedness of mental and physical health.

Detailed History Gathering:

  • The form delves into both current concerns and past mental health history. This is vital for identifying patterns, potential diagnoses, and relevant past experiences.
  • Questions about suicidal ideation and harm to others are essential for assessing safety and risk.

Service Suitability Assessment:

  • The inclusion of detailed descriptions and suitability questions for various service options (individual, group, couples/family, workshops) empowers clients to make informed choices.
  • This section demonstrates a client-centered approach, prioritizing individual needs and preferences.

Emphasis on Client Empowerment:

  • The "Client Questions Regarding Service Suitability" section encourages active participation and open communication.
  • By asking about goals, scheduling preferences, and financial concerns, the form acknowledges the client's agency and practical needs.

Ethical Considerations:

  • The consent and confidentiality section underscores the importance of ethical practice and client rights.
  • This section provides clarity and transparency regarding the limits of confidentiality.

Variety of service options:

  • The form provides a good variety of service options, and also allows for specialisation within those options. This is very important, as a client may need a very specific type of therapy.

Focus on strengths:

  • The form asks "What are your strengths?" This is very important, as it helps the therapist to see the client as a whole person, and not just a set of problems.

Insights and Considerations:


Potential for Overwhelm:

  • The form's comprehensiveness could be overwhelming for some clients, especially those experiencing significant distress.
  • It's essential to provide support and reassurance during the intake process, and to offer assistance with completing the form.

Cultural Sensitivity:

  • It's crucial to ensure the language and questions are culturally sensitive and inclusive.
  • Consider adding questions about cultural background and preferred communication styles.

Adaptability:

  • The form should be viewed as a template and adapted to suit the specific needs of the practice and client population.
  • For example, a practice specializing in trauma recovery may need to include more detailed questions about trauma history.

Digital vs. Paper:

  • Consider offering both digital and paper versions of the form to accommodate client preferences.
  • Digital forms can streamline data entry and improve efficiency.

Follow-Up:

  • The intake form is just the first step. It's essential to have a clear process for reviewing the information and conducting a thorough initial consultation.
  • The information gained from the form should be used to create a personalized treatment plan.

In essence, this client intake form provides a strong foundation for building a successful therapeutic relationship. By prioritizing client information, service suitability, and ethical considerations, it promotes effective and compassionate mental health care.


 

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