Intake Form

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*

Age*

Gender*

Male
Female

Marital Status

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?*

Please list any specific health problems you are currently experiencing*

How would you rate your current sleeping habits?*

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?*

Are you currently in a romantic relationship?*

Yes
No

For how long?*

How would you rate your relationship?*

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?*

General Information

General Health & Mental Health Information

Family Mental Health History

Additional Information

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