Kimberly DeLamar Matties : Online Video Therapy, Psychotherapy in Laguna Niguel, CA

4. Ethnicity

Other (please specify)

5. Referral Source

Please specify above

6. Responsible Party

Responsible Party Name (If different from client):
Responsible Party Phone:
Responsible Party Address, City, Zip:

7. Employment

Employer

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...

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...

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)

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

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...

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

inadequate

insecurity

jealousy

regret

resentment

sad

shame

unloved

worthless

10. My fantasy of the ideal relationship I would like to have or be in is...

11. What I believe could lead to this ideal relationship is...

12. If I could let go of just one thing that might really make a difference to my relationship that would be...

13. When you think about seeing a therapist for your relationship or marriage, how do you imagine therapy could really make a difference?

1. In regard to my work I am...

2. The type of work I do is...

3. I have been at my present job for...

4. My major dissatisfactions with my work are...

the job itself

my career

my coworkers

my boss

my income

no major dissatisfactions

Other (please specify)

1. In regard to my social network I have...

virtually no close friends

one close friend

a few friends

many friends

2. My friends' influence on me is...

positive

negative

neutral

3. What I most like to do for fun or recreation is...

1. In regard to using alcohol...

I drink occassionally

I drink regularly

I drink daily

I do not drink at all

2. When I drink, the number of drinks I usually have is...

3. I consider my drinking to be...

a definite problem

a growing problem

a potential problem

not a problem

4. In regard to illegal drug use...

I do not use any illegal drugs

I have experimented on an occassional basis in the past but no longer use

I used for a short period of time but no longer use

I used for a long period of time but no longer use

I currently use drugs on an occasional basis

I currently use drugs on a regular basis

5. My primary drug of choice is...

pot

speed

psychedelics

cocaine

heroin

sedatives

Other (please specify)

6. I use drugs...

daily

3 to 6 times a week

1 to 2 times a week

1 to 3 times a month

on an occasional basis

7. I consider my drug use to be...

a definite problem

a growing problem

a potential problem

not a problem

1. My father...

is alive and I live with him

is alive and lives nearby

is alive and lives some distance away

is recently deceased

died some years ago

died when I was a teen

died in my early childhood

2. In general, I would describe my father as...

argumentative

physically abusive

sexually abusive

critical

absent

emotionally distant

supportive and nurturing

caring

Other descriptions

3. The ways that I am like my father are...

The ways that I am like my father are...

4. Major feelings I have with my father are

abandonment anger betrayal confused disappointment distance fear	guilt hurt inadequate insecurity regret resentment sad	shame unloved worthless warm loving respect
Other (please specify)

5. My mother...

is alive and I live with her

is alive and lives nearby

is alive and lives some distance away

is recently deceased

died some years ago

died when I was a teen

died in my early childhood

6. In general, I would describe my mother as...

argumentative

physically abusive

sexually abusive

critical

absent

emotionally distant

supportive and nurturing

caring

Other descriptions

7. The ways that I am like my mother are...

8. Major feelings I have with my mother are...

abandonment anger betrayal confused disappointment distance fear	guilt hurt inadequate insecurity regret resentment sad	shame unloved worthless warm loving respect
Other (please specify)

9. If I could be free of one major, persistent emotion or feeling in relationship to my parents that might really make a difference in my life, that would be...

1. Regarding previous therapy...

I have never been in therapy before

I have been in therapy on one previous occasion

I have been in therapy on two previous occasions

I have been in therapy on three previous occasions

I have been in therapy on more than three previous occasions

2. The last time I was in any type of therapy was...

less than a year ago

a couple of years ago

several years ago

many years ago

never been in therapy

3. The type of therapy I've been in before was...

individual therapy

couples therapy

family therapy

group therapy

self help

personal growth workshops

personal growth seminars

life coaching

none

Other (please specify)

4. I was in therapy for...

I have never been in therapy

a problem similar to the one I have now

a different problem (specify below)

5. The last time I saw a therapist my experience was...

positive

neutral, received limited benefit

negative

6. What made therapy positive or negative was...

1. I have been hospitalized for psychiatric or substance abuse problems...

never

on one previous occasion

on two previous occasions

on three previous occasions

on more than three previous occasions

years/reasons

2. Psychiatric medications I am now taking are...

None

Current medications/dosages/for how long

3. These medications are prescribed by...

Not applicable

Doctor's Name and Phone

4. Would it be okay to contact your doctor if necessary?

Not applicable

Yes

5. In the past I have received major medical treatment for...

No major medical treatment

the following medical problems:

6. Currently I am being treated for...

I am not being treated for any medical problems

an infection

a nutritional or metabolic disorder

a blood disorder

a nervous system disorder

a circulation disorder

a respiratory disorder

a digestive disorder

a genitourinary tract disorder

pregancy or related childbirth complications

a skin disorder

a musculoskeletal disorder

a congenital disorder

an injury

7. Physical symptoms I am having and not being treated for are...

None

Symptoms

8. The number of cigarettes I smoke per day are...

I do not smoke

1 cigarette a day

between 2 and 5 cigarettes a day

between 5 and 10 cigarettes a day

between 10 and 15 cigarettes a day

about a pack a day over a pack a day

Other (please specify)

9. In the past year I have exercised...

regularly

occasionally

sporadically

rarely

not at all

10. I consider myself to be...

in excellent health

in good health

in fair health

in poor health

11. I consider my diet to be...

very healthy

questionably healthy

not very healthy

often changing

1. Three results I am hoping to gain out of therapy are...

2. My problems would seem to clear up...

if others would change

if I would change

if I understood myself better

if I could express myself better

if I could let go of the past

if I could get rid of certain emotions

if I could make a decision

if I could change my thinking

if I had some direct answers

Other (please specify)

Intake Evaluation Form Please complete the confidential questionaire.

2. Gender

3. Marital Status

4. Ethnicity

5. Referral Source

6. Responsible Party

7. Employment

Presenting Problem

1. The main problem I am seeking help for is...

2. I've experienced this problem over the past...

3. On a scale of 1 to 10 (1=mild and 10=severe), I would rate the severity of this problem as a...

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...

5. The areas of my life impacted most by this problem are...

1. The major emotions I have been experiencing are...

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...

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...

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...

8. As far as any thoughts of harming anyone...

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...

3. I have been married/in this relationship for...

4. The number of children I have is...

5. In regard to parenting, my partner and I...

6. My general approach to parenting is to...

7. Major feelings I have with my children are...

8. My commitment to this marriage/relationship is...

9. Major emotions I have with my partner are...

10. My fantasy of the ideal relationship I would like to have or be in is...

11. What I believe could lead to this ideal relationship is...

12. If I could let go of just one thing that might really make a difference to my relationship that would be...

13. When you think about seeing a therapist for your relationship or marriage, how do you imagine therapy could really make a difference?

1. In regard to my work I am...

2. The type of work I do is...

3. I have been at my present job for...

4. My major dissatisfactions with my work are...

1. In regard to my social network I have...

2. My friends' influence on me is...

3. What I most like to do for fun or recreation is...

1. In regard to using alcohol...

2. When I drink, the number of drinks I usually have is...

3. I consider my drinking to be...

4. In regard to illegal drug use...

5. My primary drug of choice is...

6. I use drugs...

7. I consider my drug use to be...

1. My father...

2. In general, I would describe my father as...

3. The ways that I am like my father are...

4. Major feelings I have with my father are

5. My mother...

6. In general, I would describe my mother as...

7. The ways that I am like my mother are...

8. Major feelings I have with my mother are...

9. If I could be free of one major, persistent emotion or feeling in relationship to my parents that might really make a difference in my life, that would be...

1. Regarding previous therapy...

2. The last time I was in any type of therapy was...

3. The type of therapy I've been in before was...

4. I was in therapy for...

5. The last time I saw a therapist my experience was...

6. What made therapy positive or negative was...

1. I have been hospitalized for psychiatric or substance abuse problems...

2. Psychiatric medications I am now taking are...

3. These medications are prescribed by...

4. Would it be okay to contact your doctor if necessary?

5. In the past I have received major medical treatment for...

6. Currently I am being treated for...

7. Physical symptoms I am having and not being treated for are...

8. The number of cigarettes I smoke per day are...

9. In the past year I have exercised...

10. I consider myself to be...

11. I consider my diet to be...

1. Three results I am hoping to gain out of therapy are...

2. My problems would seem to clear up...

Intake Evaluation Form

Please complete the confidential questionaire.