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Intake Questionnaire

New clients, please fill this out before your first appointment. When you press Send, it goes straight to Rudi.

Prefer paper? Download the PDF to print and bring with you.

Rudi Lion, MA, MFT · Lic.# MFT 48741 · 2020 Alameda Padre Serra, Suite 217 · Santa Barbara, CA. 93103 · (805) 453-4826

About you

Relationships and family

Children’s Names

Sibling’s Names

Parent’s Names

Health

Current Drug Use

Caffeine

Nicotine

Sugar

Alcohol

Marijuana

Cocaine

Do/did your parents abuse alcohol/drugs?

Therapy before

Have you been in therapy before?

A little more about you

Yes or no

Please Answer the Following Questions With a Yes or No:

1. Would you describe your adulthood as traumatic?

2. Would you describe your childhood as traumatic?

3. Have you gained or lost more than 10% of your regular weight in the last six months?

4. Are you sleeping well?

Trouble falling asleep?

Trouble with early awakening?

5. Are you eating poorly?

6. Do you have any trouble with eating?

7. Do you have any close friends?

8. Are you fatigued or tired frequently?

9. Are any members of your family mentally ill?

Physically ill?

10. Are you experiencing any sexual difficulties?

11. Are you experiencing any legal difficulties?

12. Are you currently experiencing major stressors or anxieties?

13. Are you currently suicidal?

Have you ever been?

14. If yes, do you have a plan or a method?

15. Has anyone in your immediate family committed suicide?

16. Are you bothered by strange and uncontrollable thoughts or urges?

17. Are you or have you ever been homicidal?

18. Do you have any addictions?

19. Are there questions that I didn’t ask that I should have?

When you press Send, your answers go to Rudi by email as a PDF. They are not stored on this website.