Intake Questionnaire
Name:
What has prompted you to seek treatment now?
What are your goals for treatment?
1.
2.
3.
Have you had any prior psychological treatment?
No Yes (If yes, please complete:)
Age/ Date Provider/Clinic Reason for treatment. Was it helpful?
Please check any of the following significant stressful life events that have occurred in the past year and briefly describe:
Arguments with family/friends/ neighbors:
Friendship problems:
Death of a family member or significant person:
Move/ Change of residence:
Trauma:
Break up/separation/divorce:
Serious Illness of a family member:
Unemployment:
Financial stress:
Other:
Do you have any medical problems or diagnoses? If yes, please describe.
Form continued on the next page
Kathryn B. Miller, PhD
Licensed Psychologist
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