Psychotherapy Intake Questionnaire Confidential – Please complete before your first sessionImportant: If you are in crisis, experiencing thoughts of self-harm, or at risk of harming others, please seek immediate support from local emergency services or a crisis hotline in your area. This form is not monitored in real time.Full Name *Date of Birth *Email AddressPhoneYour Therapy Journey: What brings you to therapy at this time?What are your primary goals for therapy?Emotional & Mental Health Check-InPersistent sadness or depressionAnxiety, panic attacks, or excessive worryDifficulty sleeping or nightmaresThoughts of self-harm or suicideDifficulty managing angerHearing voices or seeing things others don’tIntense mood swings or emotional instability(Please check any that apply)Safety & Risk Screening: In the past 6 months, have you had thoughts of harming yourself or others?YesNoHave you ever been hospitalized for mental health reasons?YesNoDo you experience any of the following?Delusions or paranoiaSevere dissociation or memory gapsSelf-harming behaviors (e.g., cutting, burning)Impulsive behaviors (e.g., reckless spending, gambling)(Please check any that apply)Have you been diagnosed with any of the following?Borderline Personality Disorder Bipolar Disorder I or IIPsychotic Disorder (e.g., Schizophrenia)Post-Traumatic Stress Disorder (PTSD)Substance Use Disorder(Please check any that apply)Are you comfortable receiving therapy via telemedicine?YesNoUnsureDo you have a private, safe space for online sessions?YesNoFinal Thoughts Is there anything else you’d like to share before we begin?Thank you for sharing. Your responses will help us determine if telemedicine is the best fit for your needs. If in-person or specialized care is recommended, we will discuss appropriate referrals.Submit