Client Intake Form

for Integrative Psychotherapy

Complete this form online, no later than 48 hours before your first session. Please note that your responses may not be saved if you leave this page.

Answer all the ‘Required‘ questions in every section (if they’re not relevant please type ‘none’ or ‘N/A’). Some questions are only relevant for the person who has parental responsibility for a client aged 16 or under.

Section 1: General Information

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Thank you

for completing the Client Intake Form

Today’s Date (DD/MM/YYYY)

Are you the client?

If you’re filling in the form for a client, please answer the next 2 questions.

What is your full name and relationship to the client?

Is the client helping you fill in this form now?

Section 2: Client Personal Information

Full Name

Preferred Name (if different from above)

Date of Birth

Age

Address, including postcode

Occupation / Educational setting and year of study (if relevant)

Section 3: Contact Details

If you’ve parental responsibility for a client aged 16 or under, give your contact details (never give their contact details).

Mobile Phone

Landline Phone

If you’ve parental responsibility for a client aged 16 or under, and you’ve already included your contact details above, please include the details of another adult with parental responsibility for the client aged 16 or under.

Next of Kin Name

Next of Kin Email

Next of Kin Mobile Phone

Section 4: Client Medication, Alcohol and Drugs

List all current medication taken and what they’re for.

List all current supplements (vitamins, minerals and herbs) taken and what they’re for.

Current alcohol intake, what type and how much a week.

Current caffeine intake (drink and food), what type and how much a day.

Current and past smoking and/or vaping, when and how much a day.

Current and past recreational/illegal drug use, what type, when and how much a week.

Section 5: Client Health, Development and Disabilities

Current and past mental health issues (anxiety, depression, bipolar disorder, self-harm or suicidal ideation, trauma, risky behaviour etc.), when, and if a diagnosis was given by a medical professional.

Current and past medical and physical issues, and when.

Developmental issues, and if there is a professional diagnosis or if it is awaiting assessment.

If you have any disabilities, do you need any reasonable adjustments made for us to work together?

Sleep – How long do you sleep for? Do you sleep right through or is it broken? Does it change when you’re stressed, angry or upset?

Appetite – Is it healthy and balanced? Do you feel hungry? Do you binge eat or restrict your food? Does it change when you’re stressed, angry or upset?

Section 6: Client, Relationships and Support

What do you enjoy doing? What interests you?

What are your strengths (things you are good or skilled at)?

What helps you cope when you’re stressed, angry or upset?

Who do you live with?

Are you in a current relationship?

Who supports you when you’re stresssed, angry or upset (partner, family, friends etc.)?

Section 7: Help

What do you want me to help you with?

If you’re filling this in for a client aged 16 or under, please answer all of the following questions:

The answer given in the previous question is…

Does the client think they need this help and support now? And why?

By typing your Full Name in the box below, Holistic Health York accepts this as your (the client or the person named below, who has parental responsibility for a client aged 16 or under) electronic signature.