New Client Intake Form

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Malwina Andruczyk, LCSW, SIFI

When your intake form is received, Malwina will contact you to set up a 15 minute phone screening and you will be on your way to your first session.

Please provide your full name *

Date of birth *

YYYY

What gender pronouns do you use? *

Such as they/them/theirs, she/her/hers, he/him/his, or whatever feels most comfortable and true to you

How do you describe your racial and ethnic identities?

Email Address *

Phone Number *

Address *

What are some good times to reach you for a follow up call? *

What brings you to counseling at this time? *

Is there a something specific, such as a particular event? Be as detailed as you can.

What are your goals for counseling? *

Have you seen a mental health professional before? *

Yes

If you have been in treatment before, when was your last mental health session?

What do you consider your greatest strength?

Creative projects/practices (art, music, writing, movement etc.):

Spiritual beliefs:

Self care practices:

Are you engaged with any other healers/doctors/guidance?

If taking prescription medication for mental health--please list here.

Relationship to drugs & alcohol & if you are currently using either: *

Any suicidal thoughts, plans, self harm, or extreme coping? (I understand extreme coping to be all of the above, or any other coping we use when we are in the most pain, and that it is all an attempt to soothe the nervous system. I emphasize this because there can be shame around these coping techniques.) *

Have you ever been hospitalized for a psychiatric issue? If so--when was your last date of hospitalization? *

Describe your current living situation. Do you live alone, with others, with family, etc? *

Please check any of the following you have experienced in the last 6 months. *

Trouble concentrating

Decreased appetite

Increased appetite

Joy

Difficulty sleeping

Low motivation

Sense of connection to something larger than yourself

Self isolation (avoiding friends/family)

Hopefulness

Fatigue/low energy

Relaxed state of mind

Changes in your self esteem

Irritability/anger

Depressed mood

Anxiety

Hopelessness

Other:

Required

Anything else you would like me to know? *

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