Intake Form

please fill out the form below

Please provide the following information and answer the questions below

Please note, information you provide here is protected as confidential information.
General Information
Name*
First Middle Last
Are you over 18?*
- Yes
- No
Name of Parent/Guardian (if under 18 years)*
First Last
Birth Date*
MM slash DD slash YYYY
Age*
Gender*
- Male
- Female
Marital Status
- Never Married
- Domestic Partnership
- Married
- Separated
- Divorced
- Widowed
Please list any children/age
Child Age
Address*
Street Address Address Line 2 City State / Province / Region ZIP Country
Cellphone*
Cellphone - May we leave a message?*
- Yes
- No
Home Phone
Home Phone - May we leave a message?
- Yes
- No
E-Mail*
May we e-mail you?
Please note: E-mail correspondence is not considered to be a confidential medium of communication
- Yes
- No
Were you referred by someone else?*
- Yes
- No
Referred by:*
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc)?*
- Yes
- No
Name of previous therapist/practioner?*
Are you currently taking any prescription medication?*
- Yes
- No
Please list prescription medication(s)*
Have you ever been prescribed psychiatric medication?*
- Yes
- No
Please list psychiatric medication(s) and date(s)*
Medication Name Date
General Health & Mental Health Information
How would you rate your current physical health?*
Poor Unsatisfactory Satisfactory Good Very Good
Please list any specific health problems you are currently experiencing*
How would you rate your current sleeping habits?*
Poor Unsatisfactory Satisfactory Good Very Good
Please list any specific sleep problems you are currently experiencing*
How many times a week do you generally exercise?*
What types of exercise do you participate in?*
Please list any difficulties you experience with your appetite or eating patterns*
Are you currently experiencing overwhelming sadness, grief, or depression?*
- Yes
- No
For approximately how long?*
Are you currently experiencing anxiety, panic attacks, or have any phobias?*
- Yes
- No
When did you begin experiencing this?*
Are you currently experiencing chronic pain?*
- Yes
- No
Please describe*
Do you drink alcohol more than once a week?*
- Yes
- No
How often do you engage in recreational drug use?*
Daily Weekly Monthly Infrequently Never
Are you currently in a romantic relationship?*
- Yes
- No
For how long?*
How would you rate your relationship?*
1 2 3 4 5 6 7 8 9 10
What significant life changes or stressful events have you experienced recently?*
Family Mental Health History
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).
Alcohol/Substance Abuse
- Yes
- No
Family Member:
Anxiety
- Yes
- No
Family Member:
Depression
- Yes
- No
Family Member:
Domestic Violence
- Yes
- No
Family Member:
Eating Disorders
- Yes
- No
Family Member:
Obesity
- Yes
- No
Family Member:
Obsessive Compulsive Behavior
- Yes
- No
Family Member:
Schizophrenia
- Yes
- No
Family Member:
Suicide Attempts
- Yes
- No
Family Member:
Additional Information
Are you currently employed?*
- Yes
- No
Please state your job title*
Do you enjoy your job? Is there anything stressful about your current work?*
Do you consider yourself spiritual or religious?*
- Yes
- No
Please describe your faith or belief*
What do you consider to be some of your strengths?*
What do you consider to be some of your weaknesses?*
What would you like to accomplish out of your time in therapy?*

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Child	Age

Medication Name	Date

Intake Form

General Information

General Health & Mental Health Information

Family Mental Health History

Additional Information

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