1Josh Whaley, MSW, LCSW

1542 Bishop Rd SW
Tumwater, WA 98512

Intake Information
Name_______________________________________________ Date of Birth_____________

Please describe the problems that are bringing you in for services
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How long have you had these issues?_______________________________________________

Please circle all symptoms that have been occurring for you over the past three months.
Depressed mood Anxiety Appetite Changes Sleep Issues
Lack of Pleasure Irritability/Anger Tearfulness Panic Attacks
Alcohol Use Drug Use Trouble Concentrating Poor Memory
Visual Hallucinations Obsessive Thoughts Impulsivity Isolating
Worry Thoughts Violent behaviors Suicidal Thoughts Self-harm
Homicidal Thoughts Disturbing Memories Racing Thoughts Mood Swings

Have you ever attempted suicide? If so how?

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Please circle if your symptoms are effecting any of the following areas in your life.
Relationships Finances Employment School
Everyday tasks Legal Recreation Other
2Josh Whaley, MSW, LCSW
1542 Bishop Rd SW
Tumwater, WA 98512

Have you ever been the victim of abuse or other forms of trauma? Please briefly summarize
below.
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Please list who is currently living in your home.

Name Age Relationship to you
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6.

Is there a history of mental health issues in your family? If so, please list the mental health
problem and relationship of the person to you below.
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Is there a history of drug or alcohol abuse in your family? If so, Please list the abuse history and
relationship of the person to you below.
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Please circle the types of mental health treatment you have participated in in the past.
3Josh Whaley, MSW, LCSW
1542 Bishop Rd SW
Tumwater, WA 98512

Counseling Psychiatric Hospitalization Medication Management

Self-help Groups Drug/Alcohol Treatment
Have you ever been diagnosed with mental health disorders? If so, please list below.
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What problems have you had with drugs or alcohol in the past?
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Please describe your use of drugs or alcohol over the past month.
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Please list current health issues below.
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Please list current medications below.
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What are your goals for therapy?
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