Intake Form - Dr Sarah Walker

Have you previously received psychological counseling?

Yes No

If yes, please describe when, where and why;

Are you currently taking prescribed psychiatric medications (antidepressants or others)?

Yes No

If yes, please list them here.

Please describe the problems you most wish help with right now:

How would you describe the intensity of the problems or concerns that brought you here?

How long have you had the current problems?

How would you describe your recent sleeping?

About the same Problem getting to sleep Problem staying asleep Problems getting and staying asleep

How would you describe your current appetite?

About the same Less than normal More than normal

How would you describe your current sexuality?

About the same Less sexual interest More sexual interest

Do you currently feel depressed? If yes, please describe the feeling.

Do you have stress on the job? If yes, please describe why.

Have you ever experienced a panic attack? If so when and how often?

If you have had a panic attack, do you fear leaving the house because of concerns about having another panic attack?

Do you find that you worry all the time?

Yes No

Are you afraid to drive?

Yes No Sometimes

Are you afraid to fly on an airplane?

Yes No Sometimes

How many alcoholic beverages do you typically drink in a week?

How many times a week do you typically use recreational drugs?

If you use recreation drugs, please describe the types of drugs you use and how you use them:

How would you describe your overall health?

Describe any current medical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.):

What medications, if any, are you presently taking?

Describe anything else you believe is relevant to your treatment:

PLEASE CHECK THE ITEMS YOU WOULD LIKE TO ADDRESS IN THERAPY

Career/Work

Health

Personal

Social Relationships

Shy with people Problems maintaining relationship Difficulty relating to people Difficulty making friends Feeling lonely Fighting in personal relationships

Family Relations/Spouse

Personal Goals

Develop assertiveness skills Develop more realistic expectations Accept personal limitations Develop clearer personal identity Develop better coping skills Increase awareness of emotional response Clarify personal goals and values

Please completed this intake form prior to our initial consultation.All information provided is strictly confidential.

Please completed this intake form prior to our initial consultation.
All information provided is strictly confidential.