I’ve copied the intake form below so you can simply hit “Reply” to this email and fill in your answers directly.
There’s absolutely no need to do this, but if you’d like to, please answer these questions honestly and openly—there are no right or wrong answers. Feel free to skip any questions that feel too uncomfortable or unclear.
Intake Questionnaire
Family of Origin
1. Identify your major caregivers (Name & Relationship):
2. List the birth order of children in your family (Name/Relationship, Age, Description):
Number of children in your family:
Your rank in birth order:
If adopted, age at adoption:
3. List other adults involved in your childhood (Adult/Relationship, Description):
Parental Information
4. Is your mother living?
Yes / No
If deceased, age at death:
If not your biological mother, describe relationship:
5. Is your father living?
Yes / No
If deceased, age at death:
If not your biological father, describe relationship:
6. If your parents were living during your childhood, were they:
Separated / Divorced / Living together
If separated or divorced, age when separated:
Age when parents divorced:
Current marital status of parents (if living):
7. Educational levels and occupations of your parents:
Mother - Education:
Mother - Occupation:
Father - Education:
Father - Occupation:
Early Family Relationships
8. Describe the physical, financial, and emotional situation of your parents at your birth or adoption:
9. Describe the relationship between your mother and father at your birth or adoption:
10. How your mother felt at birth or adoption:
How your father felt at birth or adoption:
11. Describe the relationship between your mother and father during your childhood:
Childhood Memories and Parental Relationships
(Before answering, imagine yourself as a child with your mother, then with your father.)
12. Nouns and adjectives to describe your mother:
Positive:
Negative:
13. Nouns and adjectives to describe your father:
Positive:
Negative:
Childhood Memories of Your Mother
14. Describe the happiest time with your mother:
15. Describe the worst time with your mother:
16. What did you want from your mother but never received?
17. As a child, what did you do to get approval from your mother?
Childhood Memories of Your Father
18. Describe the happiest time with your father:
19. Describe the worst time with your father:
20. What did you want from your father but never received?
21. As a child, what did you do to get approval from your father?
Childhood
22. Describe your earliest memory and your age at the time:
23. When you think of yourself as a child, how old are you?
24. Describe yourself as a child:
25. Describe feelings you had as a child:
Did you feel your caregivers noticed and responded when you were upset or scared?
Did you ever feel alone with your feelings as a child?
Did you feel like you were competing for your parents’ attention or love?
26. What was your favorite childhood story?
Describe the theme of your favorite story and how you related to the characters:
27. Identify people you felt close to in childhood:
28. Was it easy or difficult to make friends as a child? Why?
29. Did you have nicknames as a child?
Yes / No
If yes, what were they and who gave them to you?
Current Relationship With Major Caregivers
30. Describe your current relationship with your mother:
31. Describe your current relationship with your father:
32. If you had other major caregivers, identify and describe your current relationship(s):
I. Reflections
33. Reflect on your childhood and life today. How do you think your life would have been different with more ‘functional’ parents?
Separation and Independence
How did it feel for you to leave home or become more independent?
When you’re apart from people you care about, do you feel they’re still there for you emotionally?
Did you have a special object or toy you relied on for comfort as a child?
What comforts you now when you’re upset?
Self and Inner World
How do you see yourself? Are there parts of yourself you love or dislike?
Do you feel you change depending on who you’re with?
Do you notice patterns repeating in how you relate to friends or romantic partners?
Emotions and Coping
What feelings do you struggle with most (e.g., sadness, anger, anxiety)?
When you’re upset, what do you usually do to feel better?
Do your feelings ever feel overwhelming or impossible to think about?
Do you sometimes act in ways you can’t explain afterward?
Relationships and Patterns
How do you think other people experience you?
What happens when someone criticizes or disagrees with you?
Do you notice yourself idealizing someone at first, then feeling disappointed or let down later?
Do you worry people will abandon you if you show your true feelings?
Desires and Fantasies
What do you most desire in life but feel you can’t reach?
Do you have fantasies or daydreams where you feel powerful or helpless?
Are there recurring images, themes, or symbols in your dreams?
Attachment and Dependence
When you feel upset, do you reach out to someone or keep it to yourself?
Do you worry important people will leave you or stop caring?
How do you feel about needing support from others, including your therapist?
Sense of Meaning and Self-Understanding
Are there sides of yourself you hide from others—or even from yourself?
Do you feel pulled toward a deeper sense of purpose or meaning?
When you were a child, who made you feel seen and special?
Do you feel empty or worthless when you don’t get approval or attention?
Interpersonal Patterns
How do you think people feel around you?
Are there patterns in how people treat you that feel familiar from your past?
What do you imagine I (your therapist) might feel about you as we start working together?
Conflict, Guilt, and Anxiety
Do you feel guilty about angry or sexual thoughts?
Do you ever forget things or feel physical symptoms (e.g., headaches) when you’re stressed?
After you feel angry, do you worry you’ve hurt someone or fear they’ll leave you?
Dreams, Language, and Symbols
Are there words or phrases you repeat when you’re upset?
How do you define yourself in your own words?
Do you notice symbols or characters that show up often in your dreams?
Goals and Expectations for Therapy
What are you hoping to understand or change through therapy?
How do you imagine our relationship as therapist and patient?
What worries you about opening up in therapy?
History of Abuse
(The term abuse is much broader than most people realize. Abuse isn’t limited to physical harm; it can also take emotional, intellectual, and spiritual forms. Any experience that was less than nurturing—whether it involved too little (neglect, deprivation) or too much (overprotection, overwhelming control)—can be considered abusive. Fill out History of Abuse forms on all your major caregivers who were abusive to you. This includes individuals such as parents, grandparents, older siblings, aunt, uncles, older cousins, step-parents, ministers, priests, nuns, Sunday school teachers, coaches and scout leaders. Also, include strangers who abused you. Record only the time period from birth to 17 years of age.)
Type of Abuse :
Who Did It :
Age :
What Happened :
Feeling Reality Then :
Feeling Reality Now :
(Repeat if needed.)