New Client Intake Form Client Information Name First Last Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Cell PhoneHome PhoneWork PhoneDate of Birth 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 childrenChildren NamesAge How many times married? Health IssuesSignificant Surgeries in the pastPrimary Doctor How long? Prescription Medications that you are taking presentlyUse the to add multiple medicationsMedication NameDosageFrequency Please list any anti-depressants, anxiety medications, mood stabilizers you have been on in the past and when.Use the to add multiple medicationsMedication NameDosageFrequencyCurrently 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 visitWhat 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