Intake Form. This form is 100% confidential. All the information provided by you will remain private. Note: confidentiality may break if the client(s) may be an immediate danger to themselves or others. Name First Name Last Name Date of birth Status Married Single In a relationship Email * Contact No. * (###) ### #### How did you hear about us? (eg. Referral) Presenting problem: Please describe in your own words what you are struggling with at the moment. Have you been to therapy before? Yes No What would you like to achieve in therapy? Current Symptoms Pick any that apply to you at the moment: Depressed mood Unable to enjoy activities Sleep pattern disturbance Loss of interest Concentration/Focus Changes in appetite Excessive guilt Fatigue Racing thoughts Impulsivity Excessive energy Crying spells Excessive worry Panic attacks Avoidance Hallucinations Paranoia Compulsions Phobia Unhealthy Habit Suicide attempts
