Intake Questionnaire

1. What problems or symptoms do you need help with?
2. What situations trigger the problem?
3. How frequently do you experience the problem?
   Occasionally / randomly More than a few times per month More than a few times per week Daily Several times each day
4. How distressing or intense are the associated symptoms?
   Slightly Mildly Moderately Highly Extremely
5. How does this affect your work and / or personal life?
6. When you experienced the problem, what negative or unhelpful thoughts do you notice?
7. When you experience the problem, how do you feel emotionally; what feelings do you have E.g. anxious, depressed, angry?
8. When you experience the problem, how do you feel physically; what sensations or physical feelings do you notice in your body?
9. When you experience the problem, what do you do or avoid doing?
10. What makes the problem worse?
11. What makes the problem better?
12. What do you believe are the causes of the problem; what made you vulnerable to the problem in the first instance?
13. Do you experience thoughts of harming other people, yourself or ending your life?
    Never Occasionally, but never would act on them Frequently, but never would act on them Occasionally and worry that I might act on them Frequently and worry that I might act on them I have previously attempted to harm myself or others I currently harm myself or others

    Provide relevant details in the box below.

14. Please provide details of any current or recent medication.
15. Please provide details of any substance use, addictions or dependencies.
16. Please provide details of any current or past therapy undertaken for this problem or other related issues.
17. Please provide details of any current or past medical / psychological problems.
18. Please provide your GP contact details - this information will only be used with your consent or where there is unmanaged risk.
19. What's your date of birth?
20. What is your preferred contact number and email address?

If you are completing this assessment as part of our pre-assessment process, please include your initials so that we can identify your results. If you wish to receive a copy of your results by email, please also include your email address in the fields provided below:

I confirm that the information I provide on this form may be used to support my assessment, and that a copy may be sent to the email address I have given and to Good CBT.

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