Client Intake Form

Name

First Name

Last Name

Birth Date

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What are the main reasons for seeking our services?

Are you presently employed? If so, where and how long?

Are you happy with your employment?

On a scale of 1-10, what level of stress does your job have?

Are you in school? If so, what program?

Are you happy with your your program and situation?

Are you in an intimate realtionship? If so, how many years?

Are you happy within this relationship?

Partner's name, age, & occupation?

Do you have a method for relaxation or stress relief?

Do you have a religious or spiritual practice?

Do you have a regular fitness, exercise, sports activity? If so, what kind and how often?

When did you last see a health care provider and for what purpose?