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It gathers referral sources, prior mental health treatment history, presenting issues and timeline, areas of life affected, and current symptoms such as sadness, anxiety, panic, phobias, and sleep problems. 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Mission Ave. Suite 240  \nSpokane, Washington 99201  \n[asalisbury@traumainformedtherapies.com](asalisbury@traumainformedtherapies.com)  \nDate of first appointment:  \nPlease take your time in providing the following information. The questions are designed to help me begin to  \nunderstand you so that our time together can be as productive as possible. All information provided is confidential.  \nReferred by:  \n Medical Provider:    \n Insurance Provider:    \n My Website: [traumainformedtherapies.com](traumainformedtherapies.com)  \n PsychologyToday  \n Friend/Family:    \n Other:    \nHave you previously received any type of mental health services?  Yes  \n No  \nIf yes, which of the following:  Psychotherapy  \n Medication  \n Outpatient Hospitalizations  \n Inpatient Hospitalization  \nIf yes, please provide:  \nName of provider or facility:   \nLocation:   \nDates of treatment:   \nReason for treatment:   \nBriefly, what brings you in today  \nWhen did your problem first start? Within the last:  \n 30 days  \n 6--12 months  \n 2 years  \n During adolescence  \n During childhood  \nWhat areas of your life have been affected because of this problem?  \nAre you currently experiencing overwhelming sadness, grief or depression?  Yes  \n No  \nIf yes, for approximately how long?    \nAre you currently experiencing anxiety, panic attacks or have any phobias?  Yes  \n No  \nIf yes, when did you begin experiencing this?    \nPlease describe any major losses or traumas you have experienced:  \nWhat significant life changes or stressful events have you experienced recently?  \nWhat would you like to accomplish out of your time in therapy  \nFamily History  \nWhere were you born?   Where did you grow up?    \n City  \n Suburbs  \n Country  \nPlease list your parents and siblings. Please use additional space on the back if needed  \n\n| Name | Age | Relationship | Where do they live now? | If deceased, age and cause of death |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\nWho did you live with while growing up?   Mother's occupation:    \nFather's occupation?    \nIn the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.) .  \n\n| Condition | Please circle | List Family Member |\n| --- | --- | --- |\n| Alcohol/Substance Abuse | yes/no |  |\n| Anxiety | yes/no |  |\n| Depression | yes/no |  |\n| Domestic Violence | yes/no |  |\n| Sexual Abuse | yes/no |  |\n| Eating Disorders | yes/no |  |\n| Obesity | yes/no |  |\n| Obsessive Compulsive Disorder | yes/no |  |\n| Schizophrenia | yes/no |  |\n| Suicide Attempts | yes/no |  |\n| Other diagnosed mental health condition? | yes/no : which was--- |  |\n\nMarital Status:  \n Never Married  \n Domestic Partner  \n Married  \n Separated  \n Divorced--For how long?  \n Widowed: Please provide your partners name and year deceased:  \nIf married, how long have you been married for and what is your partners name:  \nOn a scale of 1-10 (best), how would you rate your relationship?    \nAre you currently in a romantic relationship?  Yes--How long?    \n No  \nOn a scale of 1-10 (best), how would you rate your relationship?   Please list any children, their names, and ages:  \n\n| Name | Age | Relationship | Name of other parent | If deceased, age and cause of death |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\nPhysical Health  \nPlease list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for off-label use. Continue on the back if needed, or provide a separate list. If you have a complicated medical profile, please supply supporting documentation to be able to facilitate a compr","cbCaikqkoreHIqGW","https://ap.wps.com/l/cbCaikqkoreHIqGW","pdf",40727,"English","# Client information and referral\n## Treatment history and current concerns\n# Symptom screening and life impacts\n## Family history and relationships\n# Physical health and medications\n## Additional information","[{\"question\":\"What information does the client intake form collect first?\",\"answer\":\"It collects identifying details such as referral source and providers, along with basic prompts about why the client is seeking therapy and when their problem began.\"},{\"question\":\"How does the form assess mental health history and current symptoms?\",\"answer\":\"It asks whether the client previously received mental health services, what types they received, and then screens for current sadness/depression, anxiety/panic/phobias, and related timing details.\"},{\"question\":\"What personal and medical sections are included beyond therapy concerns?\",\"answer\":\"The form includes family history of mental health conditions, marital and relationship details (including children), physical health, medications/supplements, sleep habits, exercise and chronic pain, plus additional information about work, stress, relaxation, spirituality, strengths, and weaknesses.\"}]","Client Intake Form - Trauma Informed Therapies | PDF"]