Intake Form

    Please complete this form as fully as possible, and then click the "Submit" button

    Name and contact information

    Name (last, first, middle initial, maiden name(if applicable):

    Date of Birth (month, date, year):

    Email address:

    Mailing Address (street, city, state, zip code):

    Phone number:

    Relationship status:

    Whom may we contact in an emergency? (name, phone number, relationship):

    Current Employment Information

    Currently employed?

    May we leave a message for you?

    Occupation

    Work Address (street, city, state, zip code)

    Method of payment

    Insurance information

    Primary Insurance Information

    Health Insurance Carrier

    Policy number

    Group Number

    Subscriber’s name

    Subscribers Phone Number

    Subscriber’s Address (street, city, state, zip code)

    Subscribe’s Date of Birth

    Subscriber’s Social Security Number

    Other Insurance Information

    Health Insurance Carrier

    Policy number

    Group Number

    Subscriber’s name

    Subscribers Phone Number

    Subscriber’s Address (street, city, state, zip code)

    Subscribe’s Date of Birth

    Subscriber’s Social Security Number

    Background Information

    Ethnic background

    Religious background

    Family of Origin (Growing Up)Please list parents,
    siblings, step-family members (name, relationship, age, health)

    Current Living Situation Please list everyone in the home,
    including pets(name, relationship, age, date of birth, gender)

    Number of children

    Why are you seeking counseling? (chief complaint)

    When did this start, or when did you first notice the chief complaint?

    Medical background

    Primary physician

    Clinic name

    Current illnesses or injuries

    Please list current prescription medications (medication, dosage, frequency, purpose (e.g., Lipitor, 40mg, 1X/day, lowers cholesterol))

    Please list any other non-prescription medications used within the last year on a regular basis

    Substance use

    Do you smoke?

    If yes, how many cigarettes per day?

    Do you drink coffee or other caffeinated drinks?

    Cups per day of caffeinated?

    Cups per day of decaffeinated?

    How often do you drink alcohol?

    How often do you consume recreational drugs?

    Educational Background

    High school completed?

    College completed?

    Degree

    Veteran Information

    Are you a veteran?

    If yes, branch of service and dates

    Who referred you to our practice?(Name, address, phone)

    Please check any symptoms you have experienced in the last 6 months

    Could you describe any other symptoms you've had?

    Have you had previous psychotherapy?

    If yes, please give therapist’s names and dates

    Are you currently involved in psychotherapy elsewhere?

    If yes, contact information for therapist (Name, Address, City, Zip, Phone)

    Past hospitalizations for psychiatric reasons (dates, and reason for admission)

    Comments are closed.