Intake Form

Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Intake Form

Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Ok to leave a message?*
- Yes
- No
Cell/Other Phone
Ok to leave a message?*
- Yes
- No
Email
Ok to leave a message?*
- Yes
- No
Date of Birth
MM slash DD slash YYYY
Age
Please enter a number from 1 to 100.
Gender/Identity
Please list any children/age:
Occupation/School:
What type of therapy have you had in the past?
Are you currently taking any medication?
- No
- Yes
If yes, please list*
Please list any health problems you have or have had:
Are you currently experiencing overwhelming sadness, grief or depression?
- No
- Yes
If yes, please describe and for how long:*
Are you currently experiencing anxiety, panic attacks or have any phobias?
- No
- Yes
If yes, please describe and for how long:*
What significant life changes or stressful events have you experienced recently:
With whom do you live?
Please check if there is a family history to any of the following:
- Alcohol/Substance Abuse
- Anxiety
- Depression
- Domestic Violence
- Suicide
- Schizophrenia
- Disorders
- Obsessive
- Compulsive Behavior
If so, please list family member:
What else would you like me to know about you?
What do you enjoy doing in your free time?
What do you hope to accomplish out of your time in therapy?
Date*
MM slash DD slash YYYY
Signature*
Phone
This field is for validation purposes and should be left unchanged.

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