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I ntake Assessment
Christina Branco Psychotherapy
308 Wellington Street, Kingston, ON, K7K 7A8
613.329.7400

Name: Date:
Date of Birth:
Fami l y of Ori gi n Hi story
(please include yourself in this table)
Family
Member
Name Age Occupation Personality
Emotional
Health
Comments
(roles,
dynamics,
relationship)
Father





Mother





Oldest
Child





Next
Oldest





Next
Oldest





Youngest
Child






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Fami l y Hi story

1. Do you know if your mother had any problems with your birth?



2. Are you your parents natural Child? Where you a planned child?



3. Did your parents tell you what kind of a baby/child you were?



4. Did you learn to walk by age one and talk by age two? Did you experience any
developmental difficulties as a child?



5. Who were you closest to growing up?



6. Describe your family life
a. Economically:



b. Socially:



c. Culturally:



d. Religion:



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7. Describe your parents marriage. Were they affectionate? How did they deal with
conflict?

8. Did anyone in the family or extended family become hospitalized for mental illness or
emotional reasons?

9. Including yourself and your family have there been or are there currently any suicidal
thoughts or attempts? (if the clients response is yes, see Addendum)

10.Who disciplined you?

11. What personality features do you have that your parents also have?

12. What did your parents communicate to you about your worth and worth of others?

13. List five things you needed from your mother/father that you dont feel you got.
1.

2.

3.

4.

5.
14. If you had miraculous powers to change your family and childhood experiences in
any three ways, what would you choose?
1.

2.

3.
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Educati onal and Devel opmental Hi story

1. What was your first day of school like?




2. How many home moves and school changes occurred during school years?




3. Did you have a group of friends during the first six grades?




4. What was your personality during your early teen years?




5. Were you supported entering into puberty?




6. Describe your relationship with peers and friends during your teenage years.




7. Describe your relationship with teachers during your teenage years.




8. What was your first date like?




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9. How old were you with your first sexual experience?




10. Were you ever sexually abused?




11. What is your sexual orientation or preference?




12. How old were you when you left home? Why did you leave?




13. Did you attend college or university?




14. How old were you when you first went to work?




15. Describe your relationship with bosses and co-workers.










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Present Fami l y
Please include in stepchildren, deaths, miscarriages, and terminated pregnancies.

Partner:
( husband , wife, etc.)

El dest Chi l d:


Next Chi l d:


Next Chi l d:


Next Chi l d:

1. How do you feel about your present family?





2. What roles or dynamics do you see playing out? How do family members get along?





Si gni fi cant Fami l y and Fri ends
Please include past and current as well as platonic and romantic.
1.

2.

3.

4.

5.
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Current I nformati on
1. What is your use of cigarettes, alcohol and/or drugs?


2. Has anyone ever complained of your use or has it gotten in the way of work, family
or social relationships?


3. Do you have an eating disorder? If not, have you in the past?


4. Have you had any past arrests, warrants, charges or suits against you?


5. What are some of the ways you choose to escape from feelings or problems? (i.e.,
shopping, watching TV, etc.)


6. Are you currently taking prescription medication? If yes, what medication and what
was it prescribed for?


7. Do you have a support network or a satisfactory group of friends?


8. Have you been to a counselor in the past? If yes, what kind of therapy and why did
you leave?


9. What are the areas of stress in your life at this time?


10. Would you describe yourself as a spiritual person?


11. What are your goals for therapy?


12. What are your expectations of the therapeutic process?


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13. Is there anything of significance which you would like to add?
































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Addendum
1. Do you feel safe with yourself?




2. Have you thought about a method of suicide?




3. Do you live alone or do you have supportive people around you?