Please fill in the form below prior to your first session. Please note, information provided on this form is protected as confidential information.
* Required
Personal Information
Your Name *
Date
Parent/Legal Guardian (if under 18)
Primary Phone *
May we leave a message? YesNo
Cell/Work Phone
Your Email *
Please Note: Email correspondence is not considered to be a confidential medium of communication.
DOB
Age
Gender
What is your preferred pronoun? HeSheThey
Highest Education Level
Referred By (if any)
Have you previously received any type of mental health counseling (psychotherapy, psychiatric, etc.) YesNo If yes, name of previous therapist/practitioner
Are you currently taking any prescription medication? YesNo If yes, please list.
General and Mental Health Information
How would you rate your current physical health (choose one).
PoorUnsatisfactorySatisfactoryGoodVery Good
Please list any Specific health issues you are currently experiencing.
How would you rate your current sleeping habits? PoorUnsatisfactorySatisfactoryGoodVery Good
Please list any sleep issues you are currently experiencing
How many times per week do you exercise?
What types of exercise do you participate in?
Please list any difficulties you might have with your appetite or eating problems?
Are you currently experiencing overwhelming sadness, grief, or depression? YesNo
If yes, for approximately how long?
Are you currently experiencing anxiety, panic attacks or have any phobias? YesNo
If yes, when did you begin to experience this?
Are you currently experiencing chronic pain? YesNo
Please describe.
Do you drink alcohol more than once a week? YesNo
How often do you engage in recreational drug use? DailyWeeklyMonthlyInfrequentlyNever
Are you currently in a romantic relationship?YesNo
If yes, for how long?
On a scale of 1-10 how would you rate your current relationship
What significant life changes or stressful events have you experienced lately? Family Mental Health History
In the area below, identify if there is a family history of these items. If yes, please check "yes" and indicate the family member's name or member/s relationship to you in the space provided (grandmother, father, uncle, etc.).
Alcohol substance abuse?YesNo
If yes, who?
Anxiety? YesNo If yes, who?
Depression? YesNo If yes, who?
Domestic Violence? YesNo If yes, who?
Emotional, Physical or Sexual Abuse? YesNo If yes, who?
Eating Disorders? YesNo If yes, who?
Obesity? YesNo If yes, who?
Obessive Compulsive Behavior? YesNo If yes, who?
Schizophrenia? YesNo If yes, who?
Suicide Attempts? YesNo If yes, who?
Additional Information Are you currently employed? YesNo
If yes, what is your current employment situation?
Do you enjoy your work? Is there anything stressful about your current work?
Do you consider yourself to be spiritual or religious? YesNo
If Yes, describe your faith or belief:
What do you consider some of your strengths?
What do you consider some of your weaknesses?
What would you like to accomplish out of your time in therapy?
Do you have insurance? YesNo
Name of insurance?
Insurance ID number?
Do you have a co-pay? YesNo
If yes, what is it?
Do you have a deductible? YesNo
Thank you for taking the time to complete this Intake Form.
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