Intake Form

Prism of Possibilities, Christine C. Cantrell PhD

AUTOBIOGRAPHICAL INFORMATION
INTAKE FORM

Christine Cantrell, Ph.D.
Licensed Psychologist

 

 

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
MALE  
FEMALE 
DATE OF BIRTH
AGE
PLACE OF BIRTH
ADDRESS: Street
City
State
Zip
TELEPHONE: Cell
Home
HIGHEST GRADE/DEGREE OCCUPATION
PERSON TO CALL IN EMERGENCY
Name
RelationshipPhone Number
REFERRAL SOURCE
PRESENTING PROBLEM (be as specific as you can)

Estimate the severity of the above problem
Mild
Moderate
Severe
Very severe
Sexual OrientationHeterosexual Gay/Lesbian Bisexual TransgenderedPartner/Marital status Currently live with someone?
Yes No
PARTNER/SPOUSE NAMEYears Together
SPOUSE/PARTNER      Education LevelOccupation
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)
 
CHILDREN/STEP/GRAND (names, ages & brief statement on your relationship with the person) 
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
Mother 
Step-Mother 
Step-Father
SIBLINGS
(names, ages & brief statement about the relationship; if deceased, age and cause of death)
DESCRIBE YOUR CHILDHOOD IN GENERAL
(Relationships with parents, siblings, others, school, neighborhood, relocations, any school/behavioral/problems, abusive/alcoholic parent)
IF PARENTS DIVORCED: Your age at the time
Describe how it affected you at the time:
MEDICAL DOCTORS NamePhone
PAST/PRESENT MEDICAL CARE
(major medical problems, surgeries, accidents, falls, illness)
Specify all MEDICATION you are presently taking and for what.
PAST/PRESENT DRUGand/or ALCOHOL USE or ABUSE
(AA, NA, treatments)
SUICIDE ATTEMPT/S or VIOLENT BEHAVIOR
(describe: ages, reasons, circumstances, how, etc)
FAMILY HISTORY OF ALCOHOLISM, METAL ILLNESS, OR VIOLENCE
(including suicide, depression, hospitalizations in mental institutions, abuse, etc.)
FAMILY MEDICAL HISTORY
(Describe any illness that runs in the family: cancer, epilepsy, etc)
FRIENDSHIPS, COMMUNITY, & SPIRITUALITY
(Describe quality, frequency, activities, etc.)
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) 
What gives you most joy or pleasure in your life?
What are your main worries and fears?
What are your most important hopes or dreams?
Please add any other information you would like me to know about you and your situation? 

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