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Intake Form

Step 1 of 4

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Please provide the following information and answer the questions below. Please note: the information you provide here is protected as confidential information.
Please fill out and submit this form prior to your first session.
Date form completed:*
Month
Day
Year
Name*
First Last
Name of parent / guardian( if under 18 years of age )
First Last
- Date of Birth*
  Month
  Day
  Year
- Age*
- Gender Identity:*
- Marital Status:*
  - Married
  - Never Married
  - Domestic Partnership
  - Separated
  - Divorced
  - Widowed
- Please list any children, including name and age:
- Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Phone*
- May we leave a message?*
  - Yes
  - No
- Email*
  
  Please note: Email correspondence is not considered to be a confidential medium of communication.
- May we Email you?*
  - Yes
  - No
- In case of emergency, contact:*
  First Last
- Relationship:
- Phone*
- May we leave a message?
  - Yes
  - No
Referred by (if any):

- Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
  - Yes
  - No
- If yes, was it helpful?
  - Yes
  - No
- Are you currently taking any prescription medication?
  - Yes
  - No
- Please list:
- Have you ever been prescribed psychiatric medication?
  - Yes
  - No
- Please list and provide dates:
PHYSICAL AND MENTAL HEALTH INFORMATION
- 1. How would you rate your current physical health?*
  - Very good
  - Good
  - Satisfactory
  - Unsatisfactory
  - Poor
- Please list any specific health problems you are currently experiencing:
- 2. How would you rate your current sleeping habits?*
  - Very good
  - Good
  - Satisfactory
  - Unsatisfactory
  - Poor
- Please list any specific sleep problems you are currently experiencing:
- 3. How many times per week do you generally exercise?
- What types of exercise do you participate in?
4. Please list any difficulties you may have with appetite or eating patterns:
- 5. Are you currently experiencing overwhelming sadness, grief or depression?
  - Yes
  - No
- If yes, for approximately how long?
- 6. Are you currently experiencing anxiety, panic attacks, or phobias?
  - Yes
  - No
- If yes, when did you begin experiencing this?
- 7. Are you currently experiencing any chronic pain?
  - Yes
  - No
- If yes, when did you begin experiencing this?
- 8. Do you drink alcohol more than four times a week?
  - Yes
  - No
- 9. How often do you engage in recreational drug use?
  - Daily
  - Weekly
  - Monthly
  - Infrequently
  - Never
- 10. Are you currently in a romantic relationship?
  - Yes
  - No
11. What significant life changes or stressful events have you experienced recently:

FAMILY MENTAL HEALTH HISTORY
In this section, please identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you (father, grandmother, uncle, etc.)
- 1. Alcohol / Substance Abuse
  - Yes
  - No
- Family Member
- 2 Anxiety
  - Yes
  - No
- Family Member
- 3. Depression
  - Yes
  - No
- Family Member
- 4. Domestic Violence
  - Yes
  - No
- Family Member
- 5. Eating Disorders
  - Yes
  - No
- Family Member

ADDITIONAL INFORMATION
1. Are you currently employed?
- Yes
- No
If yes, what is your current employment situation:
2. What do you consider to be some of your strengths?
3. What do you consider to be some of your weaknesses?
4.What would you like to accomplish during your time in therapy?
Please Email a copy to me.
- Yes, please send me a copy.
- No, thanks.
Name
This field is for validation purposes and should be left unchanged.

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