Denise O'Doherty Client Intake Form

Please fill out the information below completely prior to your first appointment.

Client Information

Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email
Cell Phone
Home Phone
Work Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Marital Status
Formal Education/ Major
Occupation
Where do you work?
How Long?
Present Position
Do you travel with your job?
Is your job a source of stress?
Do you like your job?
Where were you born?
How long have you lived in Houston?
Do you have any Religious or Spiritual Affiliation?
Live With
Relationship to this person
How Long Together?
Pets?
Children (names, ages)
Use the to add multiple children
Children Names Age
How many times married?
Health Issues
Significant Surgeries in the past
Primary Doctor
How long?
Prescription Medications that you are taking presently
Use the to add multiple medications
Medication Name Dosage Frequency
Please list any anti-depressants, anxiety medications, mood stabilizers you have been on in the past and when.
Use the to add multiple medications
Medication Name Dosage Frequency Currently Taking?
Addictions: (drug, alcohol, food, love, sex, spending, gambling, cigarettes, other)
How many days a week do you drink?
How many drinks do you average each time?
Any DWI’s?
Ever in treatment for an addiction?
If so, where and when?
For how long?
Have you ever attended a 12 Step meeting? (AA, Al-Anon, ACOA, Coda, etc.)
When?
For how long?
If in recovery, how long?
Previous Psychotherapy. With whom?
When?
For how long?
Did you achieve the results you wanted?
Do you have a pattern of putting other people’s needs and wants ahead of your own?
With whom?
Do you prefer to avoid conflict /confrontation at all cost?
Do you have a problem with managing anger, road rage or bullying?
What do you do for exercise? How often?
Do you do any volunteer work?
Do you belong to any Civic, Social or Professional Organizations?
Any in the Past?
Have you ever attended any type of Personal Development Workshop of any Kind? When? (ie: Landmark Education, More To Life, IMAGO couples or singles workshop, Marriage Encounter, Inner Child, The Mankind Project, The Woman Within, etc)
Do you consider yourself to have a good support system?
Who is in your support system?
Do you have any strong religious or spiritual affiliation?
If confidence is doing something well, and self-esteem is how you feel about yourself on a 1-10 with 10 being the highest, how do you rate your confidence?
If confidence is doing something well, and self-esteem is how you feel about yourself on a 1-10 with 10 being the highest, how do you rate your Self-Esteem?
Are you an introvert or an extrovert?
Reason for visit
What results would you like to achieve in therapy?
Referred By:
Would you like to be added to my mailing list and receive occasional information on relationships, personal growth and health?
- Yes

Children Names	Age

Medication Name	Dosage	Frequency

Medication Name	Dosage	Frequency	Currently Taking?