New Client Intake Form — Brain Health Nelson

1

Client Information

Full name

Preferred name

Date of birth

Age

Calculated from date of birth

Phone number

Email address

Please provide at least a phone number or an email address so we can contact you.

Address

Gender

Pronouns

Emergency contact

Name

Relationship

Phone

2

Reason for Referral

How did you hear about us?

Who referred you?

Have you previously seen a psychologist or therapist?

Yes No

3

Current Concerns

4

Current Symptoms

During the past month, have you experienced any of the following?

5

Mental Health History

Have you ever been diagnosed with a mental health condition?

Yes No

Have you ever been admitted to hospital for mental health treatment?

Yes No

6

Medical History

Current medical conditions

Current medications

General Practitioner (GP)

7

Alcohol and Substance Use

8

Sleep and Lifestyle

9

Family Mental Health History

Has anyone in your immediate family experienced:

10

Social History

11

Support Network

Who are the important people in your support network?

Do you generally feel supported by family or friends?

Yes Somewhat No

12

Personal Strengths

What strengths help you cope with difficult situations?

What activities, hobbies or interests bring you enjoyment?

13

Therapy Goals

What would you like to achieve through therapy?

14

Risk and Safety

These questions help your psychologist understand how best to support you.

If you are in crisis or at risk of harming yourself, please don't wait for a response to this form. Call or text 1737 (free, 24/7), call Lifeline on 0800 543 354, or in an emergency call 111.

Have you experienced thoughts that life is not worth living?

Never Occasionally Frequently

Have you had thoughts of harming yourself?

Yes No

Have you ever attempted suicide?

Yes No

Do you currently feel safe?

Yes No

If you answered "No" or would like to discuss your safety, please let your psychologist know as soon as possible.

15

Additional Information

Is there anything else you would like your psychologist to know before your first appointment?

Consent

I confirm that the information provided in this questionnaire is accurate to the best of my knowledge.

Type your full name to sign