Psychotherapy Intake Packet

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Section 1 - Personal & Relationship Information

LIST UP TO 3 PREVIOUS RELATIONSHIP(S) WITH APPROXIMATE DATES FOR THE FOLLOWING CATEGORIES - MET, LIVING TOGETHER, MARRIED, SEPARATED, DIVORCED, DEATH (Enter all that apply & label accordingly):

Children (Name, DOB, Living (Yes/No), Age, Sex, Marital Status, School or City):

Section 2 - What Brings You to Bridgepath?

PLEASE BRIEFLY DESCRIBE YOUR REASON(S) FOR SEEKING HELP AND WHAT YOU WOULD LIKE TO SEE HAPPEN AS A RESULT OF YOUR EXPERIENCES HERE.

PLACE A CHECK BY ANYTHING BELOW YOU HAVE EXPERIENCED WITHIN THE PAST 3 MONTHS:

PLEASE LIST ANY SIGNIFICANT LOSSES AND/OR TRAUMAS AND ANY RECENT MAJOR TRANSITIONS WITH DATES

IS THERE ANYTHING ELSE THAT WOULD BE HELPFUL FOR ME TO KNOW?

Section 3 - Family History

FAMILY OF ORIGIN: (Complete this section about the persons you think of as your:)

FATHER

MOTHER

Still living?

Yes

Education completed:

Elementary

High School

Grad/Professional

Still living?

Yes

Education completed:

Elementary

High School

Grad/Professional

Are your birth parents happy together?

Yes

If they were divorced, what was your age at the time?

As a child, did you feel closer to...

Father

Mother

Both

Another

List your brothers and sisters in birth order. Please also include the following information: Name, Age, Sex, Living (Yes/No), Marital Status ( S, M, W, D), Current City of Residence:

Section 4 - Faith/ Spiritual Background

Do you pray to God?

Never

Some

Often

Active in a place of worship?

Yes

Do you believe in God?

Yes

Uncertain

Change in religious affiliation?

Yes

Have you ever felt betrayed or seriously hurt by a pastor or other religous leader?

Yes

Other spiritual concerns of which you'd like for me to be aware:

Section 5 - Physical/Medical Information

Rate your physical health:

Good

Average

Poor

List important present or past illnesses or injuries: (Include any hospitalizations with dates)

Your Regular (Primary Care) Physician, If different:

Are you presently taking prescription medication? (Yes/No) If so, what medication and how much?

Do you smoke? (Yes/No) If so, how much?

Do you drink alcohol? (Yes/No) If so, how much?

Do you use other substances and if so what, how much, and how often?

Self Care (Hobbies, Exercise, Ect.):

Have you ever been treated or seen by a psychiatrist? (Yes/No) If yes, when?

Name of Psychiatrist & Approximate Number of Sessions

Name of Psychiatrist & Approximate Number of Sessions:

Have you ever been treated or seen by another counselor? (Yes/No) If yes, when?

Name of Counselor & Approximate Number of Sessions:

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