Client Intake Questionnaire — Mindful Therapist, Inc.

List the first name and age, oldest to youngest, of each family member in the spaces below. In the Other Info. Column please use ONE word to describe the family member. If any of them are no longer living, write the cause of death in the Other Info. column and the year they died.

Family Information - Current Family *

Are you: *

Married

Single

Separated

Divorced

Widowed

Living Together

Prior Partnerships or Marriages *

Early Recollections - #1 *

Type three early recollections. An early recollection is a memory of a very SPECIFIC INCIDENT that occurred when you were a child. Give your approximate age and describe how you felt.

Early Recollections - #2 *

Type three early recollections. An early recollection is a memory of a very SPECIFIC INCIDENT that occurred when you were a child. Give your approximate age and describe how you felt.

Early Recollections - #3 *

Type three early recollections. An early recollection is a memory of a very SPECIFIC INCIDENT that occurred when you were a child. Give your approximate age and describe how you felt.

In one sentence, describe: Your childhood *

In one sentence, describe: How you were parented *

In one sentence, describe: Your relationships with mother and father *

In one sentence, describe: Your relationships with siblings *

In one sentence, describe: Your relationship with your children *

In one sentence, describe: Your current relationship *

What are the 5 most traumatic events in your life? *

Any history of (check if yes)

Alcoholism

Substance Abuse

Depression/Anxiety

Domestic Violence

Eating Disorder

Sexual Abuse

Suicide/Suicide Attempts

Serious Mental Illness

Medical Information *

Please indicate any current medical problems and prescribed medication:

How frequently do you use marijuana? *

How frequently do you drink alcohol? *

Do you use any other drugs including opiates or cocaine? *

Have you ever been treated for substance abuse or been involved in 12 step program? *

Please indicate mental health problems and diagnosis *

List dates of prior experiences with psychiatrists and/or therapy *

Religious Affiliation (if any)

Spirituality is: *

Very important to me

Somewhat important to me

Not really very important to me

How do you feel these days: Your physical health *

On a scale of 1-10 with 10 being the best, how would you rate your physical health

How do you feel these days: Your eating habits *

On a scale of 1-10 with 10 being the best, how would you rate your eating habits

How do you feel these days: Your exercising habits *

On a scale of 1-10 with 10 being the best, how would you rate your exercising habits

How do you feel these days: Your sleeping habits *

On a scale of 1-10 with 10 being the best, how would you rate your sleeping habits

How do you feel these days: Your satisfaction with your relationship

On a scale of 1-10 with 10 being the best, how would you rate your relationship

These days I am mostly feeling (check one): *

MAD/ANGRY/FRUSTRATED

SAD/DEPRESSED

AFRAID/ANXIOUS/WORRIED

GLAD/JOYFUL

GUILTY/REMORSEFUL/ASHAMED

Why did you decide to start therapy at this particular point in time: *

This is how I cope with stress in my life: *

This is how I avoid dealing with problems in my life: *

What are the 3 biggest challenges in your life at this point in time: *

What I like the most about my life right now is: *

What are your strengths? *

What are your weaknesses? *

What will be different in your life when you complete therapy? *

What I want to ask my therapist is: *

Is there anything else you would like me to know? *

Thank you for submitting .

Mindful Therapist, Inc.

Ivona Bhadha, LCSW
Licensed Psychotherapist

IvonaBhadha@gmail.com

(561) 287-0942

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