Healthcare Fantasy Questionnaire

HEALTHCARE FANTASY QUESTIONNAIRE

This Healthcare Fantasy Questionnaire is a clinical intake and assessment tool used in therapeutic settings to document the content, context, and clinical impact of personal fantasies disclosed by the patient for treatment purposes. All disclosures are voluntary. The clinician will use responses to inform diagnosis, risk assessment, safety planning, and therapeutic goals. Please answer all items honestly to the best of your ability.

Patient Information

Male Female Non-binary Other Prefer not to say

Insurance Information (if applicable)

Medical & Psychiatric History

Presenting Concern and Purpose

Please describe the reasons you are providing information about your fantasies and what you hope to achieve in treatment. Include whether disclosure is for psychotherapy, medication management, couples work, or other clinical purposes.

Description of Fantasies

Provide a factual, clinical description of the primary fantasies you wish to discuss. Omit identifying details about third parties unless clinically relevant and you consent to disclosure.

Do these fantasies cause you significant distress or impair functioning? Yes No

Safety and Risk Assessment

The clinician must assess for risk of harm to self or others. Answer the following as accurately as possible. Disclosing intent or plans to harm self or others may require clinicians to take protective action consistent with mandatory reporting and duty-to-warn obligations.

Have you had thoughts of harming yourself or attempting suicide in the past year? Yes No

Have you had thoughts or intentions to harm others or engage in behaviour that could put others at risk? Yes No

Sexual and Trauma History

Indicate any history relevant to sexual health, consent capacity, or trauma. Disclosure is voluntary but clinically important. Clinicians may be required to report abuse of a minor or vulnerable adult.

History of sexual trauma or abuse: Yes No

Consent to Discuss Fantasies and Limits of Confidentiality

By signing below you authorize your clinician to discuss the fantasies you have disclosed for the purpose of clinical assessment and treatment. You understand the limits of confidentiality: clinicians must disclose information when there is a reasonable belief of imminent risk of serious harm to self or others, suspected abuse of a minor or vulnerable adult, or when disclosure is compelled by lawful court order. Clinicians may consult with clinical supervisors or other providers in a manner that protects your identity when possible.

I consent to clinical discussion of my fantasies for therapeutic purposes: I consent I decline

I acknowledge the specified limits of confidentiality and understand required disclosures that may be made without my permission: I acknowledge

HIPAA / Privacy Acknowledgement

By signing this form you indicate that you have received information regarding privacy practices related to your health information and that you understand how your protected health information (PHI) will be used and disclosed in the context of clinical care and for the limited purposes described above.

I acknowledge receipt and understanding of the privacy practices described to me: I acknowledge

Treatment Goals & Preferences

Additional Notes

Sign Now