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Client Intake Form

Please download form, fill in the information and bring it with you to your first session or complete the electronic form below.

Please note: information provided on this form is protected as confidential information.

Personal Information
Name:
Date:
Date Format: MM slash DD slash YYYY
Parent/Legal Guardian (if under 18):
Address:
Home Phone:
May we leave a message?
- Yes
- No
Cell/Work/Other Phone:
May we leave a message?
- Yes
- No
Email
May we leave a message?
- Yes
- No
*Please note: Email correspondence is not considered to be a confidential medium of communication.
DOB:
Date Format: MM slash DD slash YYYY
Age:
Gender:
Marital Status:
- Never Married
- Domestic Partnership
- Married
- Separated
- Divorced
- Widowed
Referred By (if any):
History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
- Yes
- No
If Yes, previous therapist/practitioner:
Are you currently taking any prescription medication?
- Yes
- No
If yes, please list:
Have you ever been prescribed psychiatric medication?
- Yes
- No
If yes, please list and provide dates:
General and Mental Health Information
1. How would you rate your current physical health? (Please circle one)
- Poor
- Unsatisfactory
- Satisfactory
- Good
- Very good
Please list any specific health problems you are currently experiencing:
2. How would you rate your current sleeping habits? (Please circle one)
- Poor
- Unsatisfactory
- Satisfactory
- Good
- Very good
Please list any specific sleep problems you are currently experiencing:
3. How many times per week do you generally exercise?
What types of exercise do you participate in?
4. Please list any difficulties you experience with your appetite or eating problems:
5. Are you currently experiencing overwhelming sadness, grief or depression?
- Yes
- No
If yes, for approximately how long?
6. Are you currently experiencing anxiety, panics attacks or have any phobias?
- Yes
- No
If yes, when did you begin experiencing this?
7. Are you currently experiencing any chronic pain?
- Yes
- No
If yes, please describe:
8. Do you drink alcohol more than once a week?
- Yes
- No
9. How often do you engage in recreational drug use?
- Daily
- Weekly
- Monthly
- Infrequently
- Never
10. Are you currently in a romantic relationship?
- Yes
- No
If yes, for how long?
On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
11. What significant life changes or stressful events have you experienced recently?
Family Mental Health History
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family members relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)
Alcohol/Substance Abuse
- Yes
- No
List Family Member
Anxiety
- Yes
- No
List Family Member
Depression
- Yes
- No
List Family Member
Domestic Violence
- Yes
- No
List Family Member
Eating Disorders
- Yes
- No
List Family Member
Obesity
- Yes
- No
List Family Member
Obsessive Compulsive Behavior
- Yes
- No
List Family Member
Schizophrenia
- Yes
- No
List Family Member
Suicide Attempts
- Yes
- No
List Family Member
Additional Information
1. Are you currently employed?
- Yes
- No
If yes, what is your current employment situation?
Do you enjoy your work? Is there anything stressful about your current work?
2. Do you consider yourself to be spiritual or religious?
- Yes
- No
If yes, describe your faith or belief:
3. What do you consider to be some of your strengths?
4. What do you consider to be some of your weaknesses?
5. What would you like to accomplish out of your time in therapy?

Get in Touch

info@thejwbc.com

Open Hours

Mon - Fri — 9:00am - 6:00pm
Saturday and Sunday — Closed

Book An Appointment

VI Medical Foundation Building

9150 Estate Thomas, Suite 210

St. Thomas, VI 00802

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