CBT-I Intake Assessment

Please complete this confidential questionnaire to help us understand your sleep concerns before commencing Cognitive Behavioural Therapy for Insomnia.

Personal details

Full name *

Age *

Phone number *

Your email (optional)

Sleep concerns

Which of the following sleep difficulties do you experience? *

Difficulty falling asleep Frequent awakenings overnight Waking earlier than desired Sleep not feeling refreshing

How long have these issues been present? *

How motivated are you to improve your sleep? *

What are your main goals for CBT-I?

Sleep patterns

Typical bedtime

Typical rise time

Average time to fall asleep (minutes)

Number of awakenings each night

Average total sleep per night (hours)

Do you nap during the day?

Do you work shift work?

No Rotating shifts Regular overnight shifts

Health background

Medical conditions (including sleep disorders)

Do you have any untreated medical or neurological conditions that affect sleep? *

No Yes / Unsure

Have you or others noticed loud snoring, gasping or pauses in breathing?

How would you describe your current mental health?

Medications or supplements currently used

Previous treatments tried for insomnia

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations in your usual way of life? 0 = would never doze, 1 = slight chance, 2 = moderate chance, 3 = high chance.

Sitting and reading

Watching television

Sitting inactive in a public place

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon

Sitting and talking to someone

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in traffic

Additional information

How is insomnia impacting daily life (work, mood, relationships)?

Any safety concerns (e.g., drowsy driving)?

Questions or topics you'd like to discuss

Your responses

This summary is for your records. Final suitability for CBT-I will be determined by a qualified clinician following a comprehensive review.