Intake Questions | Reaching Minds Psychiatry & Therapy

First Name *

Last Name *

Email *

What brings you to therapy? *

What are your main goals for therapy? *

Have you been in therapy before? If so, what was your experience like? *

Have you been diagnosed with any mental health conditions? If so, what are they and what treatment have you received? *

Are you currently taking any medications for mental health? (If applicable) *

Have you experienced any significant life changes or stressors recently? *

Are there any current or past relationships that have caused you distress? *

How do you cope with stress and difficult emotions? *

What are your strengths and positive qualities? *

Have you ever experienced trauma or abuse? *

Do you have any family history of mental health issues? *

How would you describe your support system? *

Are there any cultural or religious beliefs that are important to you and may impact therapy? *

What do you hope to achieve through therapy? *

Is there anything else you would like to share with me about yourself or your situation? *

How is your living condition? *

Any legal issues? *

Do you do any recreational drugs? *

Any family history of suicide? *

What is your occupation? *

Are you currently in a relationship? *

If yes to above, how long? *

If yes who would you rate your current relationship 0-10 (0 means the worse and 10 the best) *

Any Additional Comment? *

Signature *

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info@reachingmindspsych.com

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855-844-6939

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