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Client Intake Form: Mental Wellness Services
(Confidential)
Full name
*
Email
*
Phone
*
Birthday
*
Day
Month
Year
Section 1
: Your Current Concerns
What brings you here today? Please briefly describe the main reason you are seeking mental wellness services.
*
How long have you been experiencing these concerns?
*
Less than 1 month
1-6 months
6 months - 1 year
More than 1 year
How are these concerns affecting your daily life (e.g., mood, sleep, work, relationships)?
*
Section 2: Mental Health History
1. Have you ever received mental health services (e.g., therapy, counseling, medication) before?
*
Yes
No
If Yes, please briefly describe what was helpful or unhelpful:
*
2. Are you currently taking any mental health medications?
*
Yes
No
If Yes, please list them:
3. Have you ever had thoughts of harming yourself or others?
*
Yes
No
If Yes, we will discuss this further during our session to ensure your safety.
Section 3: General Health
1. Are you currently being treated for any physical health conditions?
*
Yes
No
If Yes, please list them:
2. Are you currently taking any other medications (prescription or over-the-counter)?
*
Yes
No
If Yes, please list them:
Section 5: Your Goals
What do you hope to gain from our sessions together? What would a positive outcome look like for you?
*
Submit
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