Intake Evaluation Form
Please complete the confidential questionaire.
Identifying Information
First Name
Last Name
Name you like to be called:
Spouse/Partner's Name:
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email:
Birthdate:
Age:
2
. Gender
Male
Female
3
. Marital Status
Co-Habitating
Divorced
Engaged
Married
Separated
Single
Widowed
4
. Ethnicity
African American
Arab American
Asian American
Caucasian
Hispanic American
Native American
Other (please specify)
5
. Referral Source
Friend (Name?)
Yahoo (Search Word?)
Local Publication
Newspaper Ad
Yellow Pages (Marriage)
Yellow Pages (Psychology)
Google (Search Word?)
Respond.com
4Therapy.com
Postcard
Psycholgy Today Website
Local High School (Name?)
Physician (Name?)
Psychiatrist (Name?)
Something Phishy
EDReferral.com
Internet Yellow Pages
Please specify above
6
. Responsible Party
Responsible Party Name
(If different from client):
Responsible Party Phone:
Responsible Party Address, City, Zip:
7
. Employment
Full-Time
Part-Time
Retired
Student
Unemployed
Employer
Presenting Problem
1
. The main problem I am seeking help for is...
2
. I've experienced this problem over the past...
several days
several weeks
several months
year
2 years
several years
Other (please specify)
3
. On a scale of 1 to 10 (1=mild and 10=severe), I would rate the severity of this problem as a...
1
2
3
4
5
6
7
8
9
10
4
. Over the past year the BEST this problem has been on a scale of 1 to 10 (1=best and 10=worst) has been a...
1
2
3
4
5
6
7
8
9
10
5
. The areas of my life impacted most by this problem are...
my marriage/primary relationship
my work
my family relationships
my finances
my body
my social life
my education
my future
Other (please specify)
Emotions and Behavior
1
. The major emotions I have been experiencing are...
Alienated
Angry
Ashamed
Bored
Confused
Desperate
Disappointed
Discouraged
Disgusted
Distant
Distrustful
Doubtful
Dread
Embarrassed
Empty
Failure
Fearful
Frustrated
Guilty
Hate
Hurt
Impatient
Inadequate
Indignant
Inferior
Insecure
Intimidated
Irritated
Jealous
Lonely
Longing
Lost
Numb
Paralyzed
Powerless
Pressured
Regretful
Rejected
Resentful
Resigned
Restless
Sad
Threatened
Trapped
Uncertain
Unimportant
Unloved
Vindictive
Worried
Worthless
Other (please specify)
2
. Out of all of the emotions above, the one emotion that is most intense and persistent above all the others is...
3
. The behaviors I've been struggling with are...
violent
withdrawing
losing control
not eating well
gaining weight
not focusing
dominating
blaming
moralistic
crying
compulsive actions
arguing
obsessing over things
vengeful
obsessed with my body
frantic
spiteful
controlling
not concentrating
eating too much
indecisiveness
losing weight
tiredness
binge eating
demanding
avoiding situations
being over-responsible
not sleeping well
Other (please specify)
4
. Out of all the behaviors above, the one behavior I am most disturbed about is...
5
. The body sensations I have been experiencing the most are...
jittery
rapid breathing
sweaty palms
low energy
on edge
tension
ticks
lower back tension
tiredness
pounding heart
abdominal distress
chest pain
shallow breathing
tightness in my jaw
tightness in my shoulders
feeling faint
lethargy
tightness in my chest
trembling
Other (please specify)
6
. Out of all the body sensations above, the ones that are the most intense and persistent are...
7
. As far as any suicidal thoughts are concerned...
I have no thoughts of suicide
the thought has crossed my mind but I would never do it
the thought has crossed my mind, and I have thought of ways of doing it but I would not do it
I have had some serious thoughts of suicide and I am afraid I could follow through with them.
8
. As far as any thoughts of harming anyone...
I have not had any recent thoughts of harming anyone
I have had recent thoughts of harming someone but I would not act on them
I have had some recent thoughts of harming someone and I am afraid I could carry them out
My Relationship and Current Family
1
. My major dissatisfactions in my marriage/relationship are...
2
. The areas of our relationship where this difficulty seems to show up the most are...
differences in the way we handle money
our sexual relationship
our parenting styles
the way we communicate
our lack of mutual interests
our general lack of intimacy
anger and rage
my spouse's involvement with another person
my spouse's addictive behavior
our children
trust
criticisms
in-laws
infidelity
boredom
spending time together
lack of passion
harshness
our mutual goals
the household chores
Other (please specify)
3
. I have been married/in this relationship for...
less than one year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
26 years
27 years
28 years
29 years
30 years
30+ years
4
. The number of children I have is...
Name(s)/Age(s)/Gender
5
. In regard to parenting, my partner and I...
N/A
are pretty agreeable
often disagree
sometimes disagree
I am a single parent
6
. My general approach to parenting is to...
N/A
punish misbehavior
reward good behavior
teach good behavior
try to listen
give responsibility
be a model
involve myself
Other (please specify)
7
. Major feelings I have with my children are...
anger
guilt
regret
disappointment
distance
warm
loving
Other (please specify)
8
. My commitment to this marriage/relationship is...
100%
questionable
I am having serious thoughts about leaving
9
. Major emotions I have with my partner are...
abandonment
anger
betrayal
confused
disappointment
discouraged
distance
fear
guilt
helpless
hopeless
hurt
