ADULT CLIENT INTAKE FORM

Dr. Robin Lowey & Associates Psychological Services

Please answer the following questions to the best of your abilities. These questions are to help the therapist with
the therapy process. This information is held to the same standards of confidentiality as our therapy.

Name:____________XYZ_____________________________________________________________________
(Last) (Given) (Preferred) (Middle Initial)

Birth date: __22____/___6___/__84 Age:_39_____ Gender: Male Female Transgender

Marital status: Never married Partnered Married Separated Divorced Widowed

Number of children: ___3_____ Ages:__15, 14, 10________________________________________

Current address: _____SWL_________________________________________________________

(city) (state) (zip)
Home phone:_____03134767715_____________ May we leave a message? Yes No
Cell/other: __________x_____________________ May we leave a message? Yes No
Work phone: _________x____________________ May we leave a message? Yes No
Email: _______________x___________________ May we email you?* Yes No
*NOTE: Emails may not be confidential
Who may we contact in case of an emergency: ____________x____________ Telephone numbe_____________

Referred by: Insurance company Internet search Word of mouth Advertisement Other:_______________

Primary insurance co & identification number: _____x_______________________________________________

Insurance subscriber name and date of birth: ________x______________________________________________
Secondary insurance identification number: _________x_________________________________________
Insurance subscriber name and date of birth:__________x_________________________________________

Are you currently receiving psychological services, professional counseling, psychiatric services, or any other
mental health services? Yes No
Reason for change: ________sadness, self-blaming, mood swings ________________________________

Are you currently taking any psychiatric prescription medication? Yes No

If yes, please list:_____________________________________________________________________________

Have you been prescribed psychiatric prescription medication in the past? Yes No
If yes, please list:_____________________________________________________________________________

Have you been psychiatrically hospitalized in the past? Yes No

If yes, please list dates and locations:_____________________________________________________________
General Health Information

Please provide the name, address and telephone number for your primary care physician: ___________________
__________________________________________________x___________________________________
___________________________________________________________________________________________

How is your physical health at the present time? Poor Unsatisfactory Satisfactory Good Very good

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension,
diabetes, thyroid dysfunction, etc.): ______________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Are you on any medication for physical/medical issues? Yes No

If yes, please list:_____________________________________________________________________________

Are you having any problems with your sleep habits? Yes No
If yes, circle those that apply:
Sleep too much Sleep too little Poor quality Disturbing dreams Other:___________________

Are there any changes or difficulties with your eating habits? Yes No
If yes, circle those that apply:
Eating less Eating more Bingeing Restricting Other:__________________

Have you experienced a weight change in the last two months? Yes No

Do you exercise regularly? Yes No

If yes, how many days per week do you exercise? ___________ How many minutes/hours per session: _______

Do you consume alcohol regularly? Yes No

In one month, how many times do you have four or more drinks in a 24-hour period?______________________

How often do you engage in recreational drug use? Daily Weekly Monthly Rarely Never
What kinds of recreational drugs do you use: ______________________________________________________

Are you currently in a romantic relationship? Yes No

If yes, how long have you been in this relationship?__________________________________________________
On a scale from 1-10 (10 being great), how would you rate the quality of your relationship? ______x______

In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?
___________________________________________________________________________________________
___________________________________________________________________________________________
Quick Check
Check the issues below that apply to you.

Depressed mood Panic Attacks Memory Lapse Relationship Problems

Mood Swings Phobias Trouble planning Hallucinations
Rapid Speech Repetitive Behaviors Sleep Disturbance Eating difficulties
Suicidal Thoughts Anxiety Time loss Body Complaints
Homicidal thoughts Excessive Worry Alcohol/Drug abuse Traumatic Event

Have you felt depressed recently? Yes No

If yes, for how long? _________from last 10 years_______________________________________________
Have you had any suicidal thoughts recently? Yes No
If yes, how often? Frequently Sometimes Rarely
Have you ever had suicidal thoughts in your past? Yes No
If yes, how long ago?___________8 years back________________________________________________
How often did you have these thoughts? Frequently Sometimes Rarely

Family Mental Health History

The following is to provide information about your family history. Please mark each as yes or no. If yes, please
indicate the family member affected.
Depression Yes No ___________________________
Suicide Yes No ___________________________
Anxiety Disorders Yes No ___________________________
Bipolar Disorder Yes No ___________________________
Panic Attacks Yes No ___________________________
Alcohol/Substance Abuse Yes No ___________________________
Eating Disorder Yes No ___________________________
Trauma History Yes No ___________________________
Domestic Violence Yes No ___________________________
Sexual Abuse Yes No ___________________________
Obesity Yes No ___________________________
Obsessive Compulsive Behavior Yes No ___________________________
Schizophrenia Yes No ___________________________

Religious/Spiritual Information
Do you practice a religion? Yes No
If yes, what is your faith? ______allah loves me, and he will give relief soon._______________
Occupational Information
Are you currently employed? Yes No
If yes, who is your employer?
__________school_________________________________________________________
What is your position?
_____teacher____________________________________________________________________
Are you happy in your current position? Yes No
Does your work make you stressed? Yes No
If yes, what are your work-related stressors?_______________________________________________________

Other Information

List your strengths and what you like most about yourself:____________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

List areas you feel you need to develop ___________________________________________________________

___________________________________________________________________________________________
___________________________________________________________________________________________

What are some ways you cope with life obstacles and stress?__________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

What are your goals for therapy/what would you like to accomplish?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

By signing below, I am acknowledging that I have chosen to receive mental health services in the form of
evaluation and psychotherapy from Dr. Robin Lowey & Associates Psychological Services. My decision is
voluntary and I understand that I may terminate these services at any time. I also understand that during the
course of treatment I may need to discuss material of an upsetting nature in order to resolve my problems. Further,
I understand it cannot be guaranteed that I will feel better after completion of treatment.
__________________________________ _____________________
Signature Date