My intake questionnaire is an evolution of months of working with clients. I want to make it available for everyone to use in their own practices. I pretty much have it nailed down for collecting the information I need to hit the ground running when starting with a new client. I share it when scheduling the first appointment with the client using the Client Portal and the completed form is added directly to the client's new EHR. If you find it helpful, please vote for it so it gets added to the template library.
Note on the long-answer questions, first, the question must be answered, and second, if the client tics a checkbox or answers any question "yes," the form will prompt them to add additional information. Also note that the four areas of personal health that I find most important to assess are sleep, diet, exercise, and enjoyable activity (e.g. hobby). I figure if they have all four of these areas going well, then their problem may be organic and requires the involvement of a medical doctor. Otherwise, a deficiency may be a good start for the conversation.
03-04-2020: I have added updates to the questionnaire to include questions on favorite YouTube channels, head injuries, trauma, and substance abuse. You can view the revisions by clicking the link below.
04-27-20: Updated to include clarification on committed relationship involvement, psych med data, and weed use.
05-10-20: Reorganized and created sections, added questions asking about views of seeing a therapist, increased specifics of substance use other than weed and alcohol.
I apologize in advance if the questions seem out of order, but that is how the screenshots were imported into this post. By the way, the image that appears below is 2 revisions behind.
You can download the PDF version by clicking here.
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