INDIVIDUAL QUESTIONNAIRE INDIVIDUAL QUESTIONNAIRE Form Leave this field blank Client Intake Questionnaire The information that you provide in this questionnaire will be helpful in planning services for you. Please answer each item carefully and ask for clarification if necessary. Date: Telephone: Date of Birth: Exam Date: Have you ever received psychiatric help or counseling before? Yes No Please check all of the following items that concern or pertain to you: Nervousness Shyness Depression Fears Anxiety Stomach Problems Concentration Self-Control Sexual Abuse Physical Abuse Emotional Abuse Career Choices Fatigue Relaxation Energy Level Avoidance Alcohol Use Drug Use Appetite/Eating Sadness Sleeping A Lot Trouble Sleeping Flashbacks Nightmares Suicidal Thoughts Panic Attacks Ambition Inferiority Feelings Relationships Sexual Problems Dissatisfaction Marriage/Partner Separation/Divorce Hyperactivity Mood Swings Parenting Forgetfulness Frequent Lying Money Management Aggression Perfectionism Self-Criticism Headaches Anger Decision-Making Body Image Sexual Identity Self-Injury Please list all members of your current household: Family History Work History Are you satisfied with your present employment? Yes No Highest education level Spirituality Sexual History I identify as heterosexual homosexual bisexual other Chemical Use History Thank you for completing this questionnaire. Send
