Individual Intake Form Book An Appointment Intake Form Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information. Be sure to hit 'Submit' when you are finishedName* (First) (Middle Initial) (Last) Name of Parent/Guardian (if under 18 years) (First) (Middle Initial) (Last) Date of Birth* MM slash DD slash YYYY AgeGender* Male Female Prefer Not to Answer Marital Status* Never Married Domestic Partnership Married Separated Divorced Widowed Do you have any children?* Yes No Please list all children (including those not living at home)Child's NameAgeDate of Birth Address* Street Address City State / Province / Region ZIP / Postal Code Home PhoneMay we leave a message? Yes No Cell/Other Phone*May we leave a message?* Yes No Email* May we email you?* Yes No *Please note: Email correspondence is not considered to be a confidential medium of communication.GENERAL HEALTH AND MENTAL HEALTH INFORMATIONReferred by (if any) Have you previously received any type of mental health services (therapy, psychiatric services, etc.)?* Yes No Previous Therapist/Practitioner 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 1. How would you rate your current physical health?* Poor Unsatisfactory Satisfactory Good Very good Please list any specific health problems you are currently experiencing 2. How would you rate your current sleeping habits?* Poor Unsatisfactory Satisfactory Good Very good Please list any specific sleep problems you are currently experiencing 3. How many times per week do you generally exercise?Please enter a number from 0 to 50.What types of exercise to you participate in 4. Please list any difficulties you experience with your appetite or eating patterns 5. Are you currently experiencing overwhelming sadness, grief or depression?* No Yes If yes, for approximately how long? 6. Have you had any thoughts of harming yourself or others?* No Yes If yes, who have you thought about harming? How do you plan to harm yourself or others? Do you have the means to harm yourself or others? 7. Are you currently experiencing anxiety, panic attacks or have any phobias?* No Yes If yes, when did you begin experiencing this? 8. Are you currently experiencing any chronic pain?* No Yes If yes, please describe 9. Do you drink alcohol more than once a week?* No Yes 10. How often do you engage in recreational drug use?* Daily Weekly Monthly Infrequently Never 11. Are you currently in a romantic relationship?* No Yes If yes, for how long? On a scale of 1-10, how would you rate your relationship?Please enter a number from 1 to 10.12. What significant life changes or stressful events have you experienced recently* FAMILY MENTAL HEALTH HISTORYIn 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 List Family Member Anxiety Yes No List Family Member Depression Yes No List Family Member Domestic Violence Yes No List Family Member Eating Disorders Yes No List Family Member Obesity Yes No List Family Member Obsessive Compulsive Behavior Yes No List Family Member Schizophrenia Yes No List Family Member Suicide Attempts Yes No List Family Member ADDITIONAL INFORMATION1. Are you currently employed? Yes No If yes, what is your current employment situation Do you enjoy your work? Is there anything stressful about your current work?2. Do you consider yourself to be spiritual or religious? Yes No If yes, describe your faith or belief 3. What do you consider to be some of your strengths?*4. What do you consider to be some of your weakness?*5. What would you like to accomplish out of your time in therapy?*6. Are you currently facing any legal issues?* Yes No If yes, please explain EmailThis field is for validation purposes and should be left unchanged.
