New Client Intake Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Age

What do you do for work?

Do you enjoy it?

Do you feel fulfilled in your job? Why/Why Not?

Are you married/in a relationship? How long?

Are you happy in your relationship Why?/Why not?

Where were you raised?

Are your parents still together?

Briefly describe your relationship with your parents?

Were you emotionally, physically or sexually abused as a child?

How old were you?

Do you have any siblings? If so how many? Ages?

Do you get along with them?

Have you ever been diagnosed with a mental health condition, if so which one(s)

What is your first memory and how old were you?

What is the worst thing that’s ever happened to you?

Do you have any phobias?

What do you do to relax?

What would you say is your worst failure?

What do you hope to accomplish in our sessions?

What are your strengths?

What are your weaknesses?

When something bothers you how is your anger expressed?

Are other people and their world view a mystery to you?

Do you have any goals? (Work, financial, physical, emotional, intellectual)

Is there something else I should know about you or your past

How did you hear about Happy Mind Happy Body?