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22833 Bothell Everett Hwy, Suite 206 Bothell, WA 98021
elaine@duncancounselingservices.com
Duncan Counseling Services
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DUNCAN COUNSELING SERVICES
Client Intake Form
Date
Client Name
What brings you here today?
What do you hope to achieve in therapy
Are you currently seeing, or have you ever seen, a psychotherapist or psychiatrist?
YES
NO
If so, please give the provider(s) name(s), dates, and briefly explain the nature of the problem(s)
Is there a family history of any type of mental illness, i.e. depression, anxiety, bipolar depression, schizophrenia, suicide?
Do you have any current/chronic health conditions, or past health conditions of which you think I should be aware?
Do you take any regular medications, including psychiatric medications? Please list medication and dosage (if known)
Please estimate the quantity of use of the below:
Alcohol
YES
NO
Drinks Per
Cigarettes
YES
NO
Packs Per
Marijuana
YES
NO
Other substances
YES
NO
Recreational computer use/video games
YES
NO
Hours Per
Send FORM