Anxiety and Depression Support
Client Intake Form

A psychologist providing professional guidance to a person experiencing anxiety and depression.

Date


I. Client Information

First Name

Last Name


Date of Birth

Gender


Preferred Pronouns

Contact Information

Street Address








Phone

Email

Emergency Contact

First Name

Last Name


Phone

Relationship

II. Referral Information (if applicable)

Referred By

Relationship to Referral Source

Reason for Referral

III. Presenting Concerns

Please describe the primary concerns that led you to seek support.

When did you first begin experiencing these concerns?

How often do you experience these concerns?

On a scale of 1-10 (1 being minimal, 10 being severe), how would you rate the intensity of your symptoms?

Please describe any specific symptoms you are experiencing.

Are there any specific triggers or situations that exacerbate your symptoms?

How are these concerns impacting your daily life

Have you experienced any significant life changes or stressors recently (e.g., loss, trauma, relationship issues)?

IV. Mental Health History

Have you ever been diagnosed with anxiety, depression, or any other mental health condition?

Have you received mental health treatment in the past?

Are you currently taking any medications for mental health or any other condition?

Have you ever experienced suicidal thoughts or ideation?

Have you ever attempted suicide?

Do you have a history of self-harm?

Do you have a family history of mental health conditions?

V. Medical History

Do you have any current medical conditions?

Do you have any allergies?


Are you currently seeing a physician or other healthcare provider?

VI. Lifestyle and Support Systems

Describe your current living situation.

Do you have a strong support system (e.g., family, friends, community)?

Describe your typical daily routine.

Do you engage in regular physical activity?

Describe your sleep patterns.

Do you use alcohol or drugs?

Do you use caffeine?

VII. Services and Suitability

Please indicate which of the following services you are interested in (check all that apply)

Suitability Questions

Are you open to exploring new coping strategies?

Are you willing to participate actively in therapy or support groups?

Do you have any scheduling limitations that may impact your ability to attend sessions?

Do you have access to a private and quiet space for online or phone sessions if needed?

Do you have any physical or cognitive limitations that may require accommodations?

Are you able to commit to regular sessions?

Are you comfortable with the possibility of being referred to other services if your needs exceed our scope of practice?

What are your goals for seeking support?

What do you hope to achieve through our services?

Are you in immediate danger to yourself or others?

VIII. Consent and Confidentiality

Confidentiality is maintained for all session information, with exceptions for harm risks or legal obligations.

I consent to the collection and use of my personal information for the purpose of providing support services.

I have had the opportunity to ask questions and have received satisfactory answers.

I understand that I can withdraw my consent at any time.

Signature

Form Template Insight

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Let's break down the client intake form and delve into its key components, highlighting the insights it aims to provide:


Overall Purpose:

  • Information Gathering: The core purpose is to gather comprehensive information about the client's mental health, medical history, and lifestyle. This data forms the basis for assessment and treatment planning.
  • Needs Assessment: It helps identify the client's specific needs, the severity of their symptoms, and the impact of their concerns on their daily life.
  • Service Matching: It allows the provider to determine the most appropriate services for the client, ensuring a good fit between their needs and the available resources.
  • Risk Assessment: It includes questions designed to identify potential risks, such as suicidal ideation or self-harm, allowing for timely intervention.
  • Building Rapport: The intake process, including the form, is an opportunity to begin building rapport and trust with the client.
  • Legal and Ethical Compliance: It ensures that the provider is adhering to legal and ethical requirements regarding informed consent and confidentiality.

Section-by-Section Insights:


Section 1: Personal Information:

  • Provides basic demographic data for record-keeping and communication.
  • Emergency contact information is crucial for safety planning.

Section 2: Referral Information:

  • Helps understand the client's pathway to seeking support.
  • Provides context for the client's presenting concerns.

Section 3: Presenting Concerns:

  • Offers a detailed picture of the client's current mental health status.
  • Highlights the frequency, intensity, and impact of symptoms.
  • Identifies potential triggers and stressors.

Section 4: Mental Health History:

  • Reveals past diagnoses, treatments, and outcomes.
  • Identifies patterns and potential vulnerabilities.
  • Uncovers potential risks, such as suicidal ideation or self-harm.
  • Family history provides valuable information concerning possible genetic predispositions.

Section 5: Medical History:

  • Helps identify any medical conditions that may be contributing to or interacting with mental health symptoms.
  • Ensures the provider is aware of any allergies or medication interactions.

Section 6: Lifestyle and Support Systems:

  • Provides insights into the client's daily routine, coping mechanisms, and support network.
  • Helps identify potential areas for intervention, such as sleep hygiene or stress management.
  • Substance usage is very important to track, as it can have a large impact on mental health.

Section 7: Services and Suitability:

  • Determines the client's preferences and expectations regarding services.
  • Assesses the client's readiness and willingness to engage in treatment.
  • Identifies any potential barriers to treatment.
  • The questions regarding immediate danger are very important, and need to be dealt with immediately if a client responds positively.

Section 8: Consent and Confidentiality:

  • Ensures that the client understands their rights and the limits of confidentiality.
  • Obtains informed consent for treatment.

Key Insights for the Provider:

  • Severity of Symptoms: The form helps determine the severity of the client's anxiety and depression, allowing for appropriate level of care.
  • Comorbidity: It helps identify any co-occurring mental health or medical conditions.
  • Risk Factors: It identifies potential risk factors, such as suicidal ideation, self-harm, or substance abuse.
  • Strengths and Resources: It highlights the client's strengths and support systems, which can be leveraged in treatment.
  • Treatment Preferences: It helps understand the client's preferences regarding treatment modalities.
  • Potential Barriers: It identifies potential barriers to treatment, such as scheduling limitations or financial constraints.

Important Considerations:


  • Client Comfort: The intake process should be conducted in a sensitive and non-judgmental manner.
  • Flexibility: The form should be used as a guide, and the provider should be prepared to ask follow-up questions and adapt the process to the individual client's needs.
  • Ongoing Assessment: The intake process is just the beginning of ongoing assessment. The provider should continue to monitor the client's progress and adjust the treatment plan as needed.
  • Professional Judgement: The information gathered from the intake form should be combined with the provider's professional judgment and clinical expertise to develop a comprehensive treatment plan.

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