INTAKE FORM
A PLACE TO TALK: Counseling Services by Ruth Parvin, Ph.D.
About Me     Welcome Letter     Confidentiality Form     Marital Form
Before you come for your first appointment, please take time to fill out those portions of this form that you feel comfortable sharing. Leave blank any questions you do not want or know how to answer. The more information you can provide, the quicker I will be able to get a clear idea of the issues we will work on together. Please use additional paper if you need it. You may mail this back to me or bring it with you.
Please print and fill out forms. Return to Dr. Ruth Parvin
2925 S.E. Taylor Portland, OR 97214
Date ___________________________
Your name  
Home phone  
Business phone  
Is it okay to leave a message if you do not answer?  
E-mail address    
Address
Family member to be contacted in case of an emergency   
Family member's phone  
Family member's address  
Your age  
Your date of birth  
Social Security Number  
How did you find out about my office?  
What type of work do you do?  
Your employer  
How many years of education have you completed?  
History
Have you had previous therapy?
Name of Therapist
Dates
Place
Reasons
     


 

     


 

     


 

Was this therapy a positive experience?  
Was medication prescribed? If so, what?  
Was the medication effective?  
If you are currently on any type of medication, please list it here with dosage and length of time you have taken it. (Many affect mental health.)  
List any health problems.  
Your current doctor  
Current doctor's phone  

Please mark any of the following problems you are experiencing.


Academic
Financial problems
Sexual assault/incest
Anxiety/stress disorder
Gender role issues
Physical abuse
Business/work related
Marital/partner problems
Sexual functioning
Drug/alcohol
Medical problems
Social skills
Eating disorder
Mood disorder - depression, etc.
Legal
Family problems
Problems with your children
Other
How long have you been experiencing the current problems?   
Please briefly describe your current problem(s) in your own words. Use last page of this form for more space if necessary.  
Family
List the people you consider to be your family members. Please put a check mark in front of the names of those who live in your current home.
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Name
Age
Relationship
     

 

       
     

 

       
       
Additional family members not in your current home

 

 

 

 
 
If you have experienced a family divorce, how old were you?  
If the divorce happened to you as a child, how old were you when your parents remarried?  
Who are the other important persons in your life? (First name and relationship.)

 

 

 

 
YES
NO
COMMENTS
Have you been in the military?
   

Dates:

Are you are sexual assault/incest survivor?
     
Is there physical/emotional violence in your family?
   

   

Have you been physically abused?
      
Have you ever been arrested?
      
Do you have problems with anger?      
Is there a family history of alcohol/drug abuse?      
Is there a family history of mental illness?      
Do you cut, burn, mark yourself?      
Have you ever had an eating disorder?      
Have you been hospitalized for medical/emotional problems?      
Do you tend to have intense relationships where you alternate between feelings of trust and betrayal/anger?      
Do you have any serious medical problems? (Many affect mental health.)      

What are two or three major things that have happened to you that are important to the way that you think about yourself?

 

 

 
Present Situation

What is your living situation currently? (Family home, roommate, etc.)?

 

 

How many hours per week are you employed? _____ In school? _____ What other major time commitments do you have?

 

 

What are some of your personal strengths?

 

 

If therapy accomplishes what you want, what will be different in your life at the end of therapy?

 

 

If religion or a particular philosophy is important to you in ways that might influence your counseling, please comment.

 

 

Can you make the commitment to bring up the issue of suicide if (or when) it is an active part of your thinking? _____ Have you had any thoughts of suicide in the last month? _____

Please answer the following questions.

PLEASE ANSWER THE FOLLOWING QUESTIONS STRONG OR GOOD ------------------------>PROBLEMATIC
How satisfactory is your current living situation?
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How satisfactory is your relationship with your family?
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How do you feel about your social skills?
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How good do you feel about your body image?
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How connected do you feel with friends and others?
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How optimistic do you feel about the future?
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How do you feel about your sexuality?
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How satisfactory is your work situation?
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In the most recent month, approximately how many days did you take medicine? _____   Drink alcohol? _____   Smoke? _____   Use drugs to alter your mood or sociability? _____   Binge on sugar? _____   Binge eat? _____   Drink too much caffeine for you? _____   Vomit? _____   Gamble? _____
Have you ever had a drug or alcohol problem? _____   Eating disorder? _____

Please use the back of this page to tell me things you feel are important for me to know.