Intake Questionnaire 2021/2022


This questionnaire will help me globally understand your situation. The more I know, the better we can get to the core cause of your symptoms. This will also help shorten our sessions, so that I will need to spend less time asking questions and more time on listening and giving advice. You will still get the chance, however, to go into further or repeated details as much as you want during the sessions. There is no need to rush.

Please feel free to fill in as extensive or as short you want; there are no rules. You can also skip questions altogether if you feel like, or add information you think is important but not asked.

Part 1: Basic information

⦁ Please give a short description of yourself. Tell me, for example, about your age, occupation and living situation.

⦁ Tell me about your hobbies, friends and how you like to fill in your free time. This helps me globally understand your personality type.

⦁ Describe some of your aspirations and goals in life.

Part 2: Psychological situation

⦁ Describe your main complaints below; why do you want to see me?

⦁ When did these complains start?

⦁ How do they affect your everyday life?

⦁ Have you ever been to a psychologist or psychiatric doctor for your symptoms before? If so, what were your diagnoses and how was your experience?

⦁ Does your family have a history of mental illness? If so, please elaborate.

Part 3: Physical assessment

It is estimated by modern scientist that 85% to 90% of all physical ailments have a psychosomatic source. Therefore, medical information is very insightful for a psychologist.

⦁ Please describe your history of illnesses and medication.

⦁ What other mild complaints do you suffer from? Nothing is too trivial (think about headaches, insomnia, etc).

⦁ Describe the intensity, duration and frequencies of (some of) these ailments.

⦁ In short, describe some illnesses that occur in your family.

Part 4: Relationships

Please describe your relationship in general of the following, include some positive and negative aspect, if applicable:
⦁ Partner:
⦁ Children:
⦁ Parents:
⦁ Siblings:
⦁ Other family:
⦁ Friends:
⦁ Acquaintances, colleagues or schoolmates:

Part 5: Miscellaneous
Is there anything you would me to take into account during the session?

Please describe your ideal therapy outcome? What do you hope to be learn, gain and discover from the sessions?

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