Green Door Therapy - Intake FormPlease try to fill out as much of this form as you can before our first session. Allow around 20 minutes. If you can fill it out before our appointment, we can make better use of our session time.Everything you say here is confidential and will not be shared without your consent. Name * First Name Last Name Age Gender / sex How would you describe your current occupational status? e.g. self-employed, retired etc If you are currently working, how would you rate your satisfaction at work? Very low Low Neither low nor high High Very high What is your relationship status? If you are currently in a romantic relationship, how would you rate your satisfaction with the relationship? Very low Low Neither low nor high High Very high Do you have any children? If so, what are their ages? Do you follow any religion? If so, which faith and how observant would you say you are? What have you noticed recently that has brought you to counselling? What are your goals from therapy? What would you like to accomplish? Who would you describe as being in your support network? Have you been to therapy before? Yes No If so, what was the reason and how was your experience? How long were you in therapy and when and why did you stop? Have you ever had any mental health diagnosis? If so, do you agree with it? Do any of your immediate family have any mental health conditions? If so, please provide details Have you ever had suicidal thoughts? Please remember this is confidential Yes No Please briefly share what your strengths are and what you like most about yourself Please briefly share what about yourself you think you need to work on How do you cope with stressful events or obstacles in life These could be coping strategies that you either think of as positive (eg yoga) or negative (drinking) Please list any current medical conditions, past surgery or significant illness e.g. chronic pain, headaches, hypertension, diabetes, thyroid dysfunction Are you currently on any medication? If so, what is it for and how long have you taken it? How much alcohol do you usually consume? Please try to be as accurate and honest as you can I don't drink 0-10 drinks per week 10-20 drinks per week More than 20 drinks per week How often do you use recreational drugs? Never Occassionally / a few times a month A few times a week Daily How would rate your overall health? Excellent Good Fair Poor Very poor How would rate your sleep quality? Excellent Good Fair Poor Very poor How would rate the quality of your diet? Excellent Good Fair Poor Very poor Have you ever either binge eaten or severely restricted your food intake? Yes No How many minutes of moderate to vigorous movement or exercise do you engage in a week? This might include brisk walking, jogging, swimming, cycling, gym or yoga Very little or none Around 30 minutes Around 30-60 minutes Around 60-120 minutes More than 120 minutes (30 minutes, four times a week) More than 180 minutes (30 minutes, six times a week) Please select any of the following you have expereinced in the past month Low mood Irritability Procrastination Insomnia Avoiding activities or people Withdrawal or isolation Crying or tearfulness Drinking too much Taking drugs Avoiding friends or family Outbursts of anger Avoiding or skipping work Being impulsive or engaging in risky activities Disturbed sleep Lack of motivation Choosing to bury yourself in work Difficulty concentrating Please select which of the following you have most noticed yourself feeling in the past month Fearful Sad Angry Calm Bored Excited Guilty Shameful Hopeful Envious / jealous Tense / stressed Relaxed Energetic Lonely Regretful Conflicted Restless Resentful Peaceful / at ease Please select which of the following you would say apply to you Depressed mood Panic attacks Relationship problems Mood swings Disturbed sleep Change in appetite Repetitive behaviours Racing thoughts or speech Anxiety Suicidal thoughts Unexplained pain Excessive worry Invasive thoughts History of trauma Alcohol or drug abuse Email * Phone (###) ### #### Emergency contact name First Name Last Name Emergency contact phone (###) ### #### What is their relationship to you? Thank you!