You are previewing NUCLEUS COUNSELING SERVICES, LLC Standard Intake Questionnaire Template. This is how it will appear in your Client Portal.

Questionnaire

Referred by:
What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can.
What are your goals for counseling?
Have you seen a mental health professional before?
Who is your primary care physician? Please include type of MD, name and phone number.
Specify all medications and supplements you are presently taking and for what reason.
If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.
Please check any of the following that apply
Please check any of the following you have experienced in the past six months
Do you drink alcohol?
Do you use recreational drugs?
Do you have thoughts or urges to harm yourself or others?
Do you have suicidal thoughts?
Have you ever attempted suicide?
Have you ever been hospitalized for a psychiatric issue?
Is there a history of mental illness in your family?
Is there a family history of any of the following (check all that apply)
Describe your current living situation. Do you live alone, with others, etc...
If you are in a relationship, please describe the nature of the relationship and months or years together.
What is your level of education? Highest grade/degree completed and type of degree.
What is your current occupation? What do you do? How long have you been doing it?
Additional information your clinician should know?