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Dr. Catherine Cain & Associates, LLC

 

 

 

Intake Form                                      Date

Referred by: Phone
My Online Therapist's Name Relationship Status
Name Current Living Arrangements
Email Address Have you been/are you in counseling before?
Home Address If "yes" please describe
City, State Level of Completed Education
Zip Code Current Employment
Age Medications you are currently taking
Gender (Sex)    
Date of Birth: (00-00-000)    

If you are experiencing serious suicidal thoughts , please stop now and phone your local suicide hotline or phone 911 or call 1-800-273-TALK (8255).  This service is also not intended for use by minors [under 18 years old].

PROBLEM CHECKLIST (check all symptoms that apply even if the heading does not apply)

DEPRESSION                                                                                            ANXIETY                                               ATTENTION

 chronic sadness  low frustration level  agitation  difficulty concentrating
 crying episodes  irritability  restlessness  difficulty organizing
 hopelessness  thoughts of suicide  excessive worry  impulsive
 difficulty concentrating  withdrawing from others  fearfulness  don't finish what you start
 weight loss  difficulty functioning at work  trembling/shaking  constantly moving/pacing
 weight gain  difficulty functioning socially  fear of loss of control  forgetfulness
 loss of appetite  low energy/fatigue  fear of dying  difficulty following directions
 over eating  reduced interest/pleasure  panic attacks  taking on too much at once
 nausea/vomiting  feelings of worthlessness/guilt  fear of leaving home  difficulty waiting
 difficulty making decisions  no interest daily activities  avoid public places  difficulty starting a new task
 recurring thoughts of death or dying sleeping too little/too much  avoid social situations  racing thoughts
 extreme lows/highs      pounding heart/ palpitations/ shortness of breath  difficulty getting to sleep
         chest pain    

STRESS/TRAUMA                                                                                                                                EATING PROBLEMS

  feeling detached from others/life  flashbacks/reliving bad experiences  underweight
 intrusive thoughts or bad memories  easily startled/upset  overweight
 nightmares  difficulty concentrating  self-induced vomiting/laxative use/exercising
 feeling tense/hypervigilance  self-abuse/cutting  obsessed with food

SUBSTANCE ABUSE                                                                                                                           THINKING PROBLEMS

 excessive use of alcohol/drugs  fail at effort to reduce use of alcohol/drugs  hearing voices others do not hear
 use of substances to cope with  legal problems related to substance use  fearful others are talking about you
 history of substance use in family  cigarette use causing health problems  seeing things others do not see
 memory loss following substance use  unconsciousness due to substance use  fearful someone is plotting against you
 health problems/accidents due to substance use  substance use causing problems with friends/family/work  feelings of being followed/stalked

OTHER PROBLEM AREAS

 excessive gambling  parent-child relationship issues  financial concerns
 high risk sexual behavior  other family conflicts    
 marital/relationship issues  divorce/custody issues    
 academic/work issues  foster care/adoption issues    

ADDITIONAL INFORMATION

Describe your problem to your therapist providing as much information as you can. You should include things like:
  1. How long the problem has been present.
  2. Circumstances that may have led up to the problem.
  3. Information about your family of origin and early years in life.
  4. Whether you have sought counseling or therapy prior to this and the outcome of that therapy.
  5. Things you have tried to help the problem so far, what worked, and what did not work.
  6. Who is involved in your problem at the present or in the past.
  7. Specific questions you have for your therapist about your problem.

 
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BEFORE A THERAPIST WILL RESPOND TO YOU.

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Last modified: 09/03/07