Adult Intake Questionnaire

Dr. Jennifer Lager, Psy.D.

Licensed Clinical Psychologist

GetAMentalEdge.com | DrJennniferLager.com

Phone: (703) 244-9656| Email: DrJennniferLager@gmail.com

Please answer all of the questions as best as you can regarding how you have been feeling in the last few weeks. If you are uncertain about how to respond to a question, give your best answer or leave it blank. If you feel uncomfortable answering a question, you may leave it blank.

First Name *

Last Name

Date of Birth

Today's Date

Have you lost interest in previously loved activities?YesNo

Do you have crying spells or feel like it?YesNo

Do you feel sad or down?YesNo

Do you find it easy to make decisions?YesNo

Have you noticed changes in your weight or appetite?YesNo

Have you had a change in your interest in sex (increase/decrease)?YesNo

Do you feel hopeful about the future?YesNo

Are you more irritable than usual?YesNo

Do you have trouble falling asleep or staying asleep?YesNo

Do you have trouble remembering things?YesNo

Do you have temper outbursts that you cannot control?YesNo

Do you feel others are to blame for most of your problems?YesNo

Do you feel nervous or shaky inside?YesNo

Do you often feel faint or dizzy?YesNo

Do you think that someone else can control your thoughts?YesNo

Have you felt more self-confident than usual?YesNo

Have you done things that are out of character for you?YesNo

Have you had more energy than usual?YesNo

Are you easily distracted so that you can’t concentrate?YesNo

Do your thoughts race?YesNo

Do you have financial problems?YesNo

Do you interrupt others in conversation?YesNo

Do you have trouble with time management?YesNo

For your entire life, do you often start, but not finish, projects?YesNo

Have you had lifelong trouble concentrating on tasks you find boring?YesNo

Do you tend to lose items necessary to perform your daily activities?YesNo

Do you function better in structured environments?YesNo

Are you impulsive?YesNo

Have you always had trouble with fidgeting or sitting still(even if you now control it)?YesNo

Do you have difficulty slowing down/relaxing?YesNo

Have you ever been concerned/felt guilty about your use of drugs/alcohol (D/A)?YesNo

Has anyone else ever expressed concern about your use of D/A?YesNo

Have you ever tried to stop using D/A or cut back for any reason?YesNo

Have you ever woken up after a night of drinking and could not remember part of the evening?YesNo

Have you ever drank in the morning?YesNo

Have you searched for sexual material online?YesNo

Have you ever believed that you needed to cut down on your use of the internet for sexual purposes?YesNo

Do you lie to conceal your sexual behavior?YesNo

Do you regret your sexual behavior afterwards?YesNo

Do you feel that your sexual behavior is not normal?YesNo

Have important parts of your life (job, family, friends, hobbies) been neglected because you were spending too much time on sex?YesNo

Have you ever been arrested?YesNo

Do you believe that others would be better off if you were dead?YesNo

Have you ever had a head injury?YesNo

Do you have any medical problems? If yes, please list belowYesNo

Caffeine Use (current and past):

Tobacco Use (current and past):

Alcohol Use (current and past):

Please list below all medications and dietary supplements that you are currently using.

Name

Purpose

Doctor Prescribing

Date

Please briefly describe what is bringing you into therapy at this time, and what you hope to accomplish in therapy.

Please list who, if anyone, you live with (Name, Age, Relationship):

SYMPTOMS/CONDITIONS

Please check all individuals (including yourself or family members) who have ever experienced the following symptoms or conditions — to the best of your knowledge.

Signature

Client/Guardian Signature *

Confidential Psychological Services

Please retain a copy of this signed consent form for your records.

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