Intake Form Please fill out this form according to what you think is important to tell me. You may answer all the questions, but you do not necessarily need to. You decide what is important and relevant for me to know about your situation. Your Name (required) Your Email (required) Subject age : Sex M F : Today’s Date : Address : Home Phone Mobil Phone OK to mention Cross-Cultural Psychology Service and/or me as your therapist if I call? Yes No How did you find me? Please check: My website Previous client Referral by another therapist Friends Referral by another organization – Please specify Another way – please specify What are the main concerns that bring you to therapy? What are your goals for therapy? What is the history of the concern(s) that have brought you to therapy? If the writing space here is not enough, please attach a file. PERSONAL HISTORY: Nationality Education: Degree Date Where Occupation Employer How long? Work phone FOR NON-THAI - THAILAND HISTORY: Arrival Date Date to Leave? Significant events in Thailand SPOUSE/PARTNER RELATIONSHIP HISTORY: Current Marital/Relationship Status Married? Yes No If married, when If not married, Living with You? Beginning time of relationship Began in Thailand Yes No Describe your present relationship with your partner What are your major challenges with your partner? Describe what you appreciate in your partner # of pregnancies # of live births Children Age Living with you? Children Age Living with you? Children Age Living with you? Any significant problems with your children? Previously married and divorced? Previous significant relationships? Dates Anything important about this (these) marriage(s) / relationship(s)? PARENTS: Mother Age Living If died, when? Father Age Living If died, when? Briefly describe your relationship with your parents as you were growing up Were your parents ever separated? If so, for how long? How old were you? With whom did you stay? Where did you stay? Briefly describe how that separation affected you Were there any unusual or notable circumstances or events during your mother’s pregnancy (your in-utero experience) and the time around your birth? SIBLINGS: Brothers (list ages) Sisters (list ages) How would you describe your relationship with your siblings as you were growing up? FAMILY & PERSONAL SUBSTANCE-MENTAL HEALTH HISTORY: Are you aware of any history of mental illness, alcoholism, or drug abuse in your family? If yes, please describe Do you have any history of mental illness? If yes, please describe Have you ever had a problem with or dependency on alcohol or drugs? If yes, please describe What is your current use of alcohol or drugs? Please describe Are you in a recovery program? If so, how long have you been in recovery? Please describe your recovery PHYSICAL HEALTH Please describe your state of health and any physical problems you may have at this time List any long-term (chronic) health problems Are you under a physician’s care? Yes No Name of physician Are you taking any medications? Please list What do you do to take care of yourself? PLANS AND HOPES FOR FUTURE – Please answer as you see fit - Plans – goals – hopes – dreams – What is important for your future? Relationship plans – goals – hopes – dreams? Work plans – goals – hopes – dreams? Where would you like to be living? What kind of a person would you like to be? PERSONAL PSYCHOLOGICAL ASSESSMENT Please name three (3) descriptive adjectives that accurately express your character: 1::2: 3: What are your psychological strengths? What are your psychological challenges? Please try to state your biggest challenge or personal dilemma in a short phrase or question for yourself: How have you attempted to investigate and/or improve yourself psychologically? PREVIOUS COUNSELING Name of Provider Dates Frequency Name of Provider Dates Frequency How strong is your desire for treatment? Very strong Moderate Can do without, if needed Please add anything else you would like me to know about you: YOUR MESSAGE Please enter This security code Then press ”send”