 AUTOBIOGRAPHICAL INFORMATIONINTAKE FORM Christine Cantrell, Ph.D. Licensed Psychologist |
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| Please fill out this biographical background form and bring it in to your first session. It will help me in our work together. All information is confidential as outlined in the HIPAA Contract form. Please print off this form and then hand-write clearly or type your answers in the spaces below. Then print off this form and bring it with you. It is not confidential to send this form through the internet. | |||
| NAME DATE | |||
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MALE
FEMALE
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DATE OF BIRTH
AGE
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PLACE OF BIRTH
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| ADDRESS: Street |
City
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| State |
Zip
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| TELEPHONE: Cell
Home |
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| HIGHEST GRADE/DEGREE OCCUPATION |
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| PERSON TO CALL IN EMERGENCY Name |
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| Relationship Phone Number |
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| REFERRAL SOURCE |
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| PRESENTING PROBLEM (be as specific as you can) |
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| Estimate the severity of the above problem Mild Moderate Severe Very severe | |||
| Sexual Orientation Heterosexual Gay/Lesbian Bisexual TransgenderedPartner/Marital status Currently live with someone? Yes No |
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| PARTNER/SPOUSE NAME Years Together |
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| SPOUSE/PARTNER Education Level Occupation |
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| PAST & PRESENT PARTNERSHIPS/MARRIAGES (years together, names & statement about the nature of the relationship/s, i.e., friendly, distant, physically/emotionally abusive, loving, hostile, physical violence) |
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| CHILDREN/STEP/GRAND (names, ages & brief statement on your relationship with the person) |
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| PARENTS/STEP-PARENT (Name/age occupation, personality, how did s/he treat you, brief statement about the relationship and if appropriate, year of death/cause of death) Father |
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| Mother |
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| Step-Mother |
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| Step-Father |
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| SIBLINGS (names, ages & brief statement about the relationship; if deceased, age and cause of death) |
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| DESCRIBE YOUR CHILDHOOD IN GENERAL (Relationships with parents, siblings, others, school, neighborhood, relocations, any school/behavioral/problems, abusive/alcoholic parent) |
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| IF PARENTS DIVORCED: Your age at the time
Describe how it affected you at the time: |
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| MEDICAL DOCTORS Name Phone |
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| PAST/PRESENT MEDICAL CARE (major medical problems, surgeries, accidents, falls, illness) |
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| Specify all MEDICATION you are presently taking and for what. | |||
| PAST/PRESENT DRUGand/or ALCOHOL USE or ABUSE (AA, NA, treatments) |
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| SUICIDE ATTEMPT/S or VIOLENT BEHAVIOR (describe: ages, reasons, circumstances, how, etc) |
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| FAMILY HISTORY OF ALCOHOLISM, METAL ILLNESS, OR VIOLENCE (including suicide, depression, hospitalizations in mental institutions, abuse, etc.) |
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| FAMILY MEDICAL HISTORY (Describe any illness that runs in the family: cancer, epilepsy, etc) |
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| FRIENDSHIPS, COMMUNITY, & SPIRITUALITY (Describe quality, frequency, activities, etc.) |
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| PAST/PRESENT PSYCHOTHERAPY (specify: month year/s (beginning, end), estimated no. of sessions, name, initial reason for therapy, Ind/Couple/Family, medication, and how helpful it was, and how/why it ended) |
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| What gives you most joy or pleasure in your life? |
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| What are your main worries and fears? |
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| What are your most important hopes or dreams? |
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| Please add any other information you would like me to know about you and your situation? |
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Intake Form
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