Psychotherapy Intake Packet

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Section 1 - Personal & Relationship Information

Current Status:

Section 2 - What Brings You to Bridgepath?

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

Behaviors:
Physical Conditions
Feelings
Thought Processes

Section 3 - Family History

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

FATHER

MOTHER

Relationship to father:
Relationship to mother:
Still living?
Education completed:
Still living?
Education completed:
Are your birth parents happy together?
What would you rate your parents' marriage as...
Would you rate your childhood life as...
As a child, did you feel closer to...

Section 4 - Faith/ Spiritual Background

Do you pray to God?
Active in a place of worship?
Do you believe in God?
Change in religious affiliation?
Have you ever felt betrayed or seriously hurt by a pastor or other religous leader?

Section 5 - Physical/Medical Information

Rate your physical health:

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