AUTOBIOGRAPHICAL INFORMATION
INTAKE FORM
Christine Cantrell, Ph.D.
Licensed Psychologist
Please fill out this biographical background form and bring it in to your first session. It will help me in our work together. All information is confidential as outlined in the HIPAA Contract form. Please print off this form and then hand-write clearly or type your answers in the spaces below. Then print off this form and bring it with you. It is not confidential to send this form through the internet.
NAME DATE:
MALE FEMALE
DATE OF BIRTH AGE
PLACE OF BIRTH
ADDRESS: Street
City
 
State Zip

TELEPHONE: Cell
Home

HIGHEST GRADE/DEGREE
OCCUPATION 		 
PERSON/PHONE NO. TO CALL IN EMERGENCY:
Name
Relationship Phone Number:
REFERRAL SOURCE
PRESENTING PROBLEM be as specific as you can:
Estimate the severity of the above problem: Mild Moderate Severe Very severe
Sexual Orientation: Heterosexual Gay/Lesbian Bisexual Transgendered
Partner/Marital status
Currently live with someone Yes No
PARTNER/SPOUSE NAME: Years Together
SPOUSE/PARTNER: Education Level Occupation
PAST & PRESENT PARTNERSHIPS/MARRIAGES
(years together, names & statement about the nature of the relationship/s, i.e., friendly, distant,
physically/emotionally abusive, loving, hostile, physical violence)
 
CHILDREN/STEP/GRAND (names/ages & brief statement on your relationship with the person)
PARENTS/STEP-PARENT (Name/age occupation, personality,how did s/he treat you, brief statement about the relationship and if appropriate, year of death/cause of death,, ):
Father
Mother
Step-Mother
Step-Father

SIBLINGS
(name/age & brief statement about the relationship, if dead: age and cause of death ):

DESCRIBE YOUR CHILDHOOD IN GENERAL
(Relationships with parents, siblings, others, school, neighborhood, relocations, any school/behavioral/problems, abusive/alcoholic parent):
IF PARENTS DIVORCED: Your age at the time Describe how it affected you at the time: 
MEDICAL DOCTOR/S Name
Phone:

PAST/PRESENT MEDICAL CARE
(major medical problems, surgeries, accidents, falls, illness)

Specify all MEDICATION you are presently taking and for what. PRINT or Type
PAST/PRESENT DRUG/ALCOHOL USE/ABUSE
(AA, NA, treatments):

SUICIDE ATTEMPT/S or VIOLENT BEHAVIOR
(describe: ages, reasons, circumstances, how, etc)

FAMILY HISTORY OF ALCOHOLISM, METAL ILLNESS, OR VIOLENCE
( including suicide, depression, hospitalizations in mental institutions, abuse, etc.)

FAMILY MEDICAL HISTORY
(Describe any illness that runs in the family: cancer, epilepsy, etc)

FRIENDSHIPS, COMMUNITY, & SPIRITUALITY
(Describe quality, frequency, activities, etc.)

PAST/PRESENT PSYCHOTHERAPY
(specify: month year/s (beginning? end), estimated no. of sessions, name, initial reason for therapy,
Ind/Couple/Family, medication, and how helpful it was, and how/why it ended):
What gives you most joy or pleasure in your life
What are your main worries and fears
What are your most important hopes or dreams
Please add any other information you would like me to know about you and your situation.