Intake Form

Name:*

First Last

Date of Initial Visit:*

Home Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth:*

Age:*

Please enter a number from 0 to 100.

Marital Status:*

Gender:

Referred By:

Home Phone:

Work Phone:

Cell Phone:

Email:*

Name of Spouse/Significant Other:

First Last

Phone:

*

Members of Family/Household:	Age:	Relationship:

Primary Care Provider:*

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:*

Are you currently receiving psychiatric services or professional counseling?*

No
Yes

Current psychiatrist or therapist's name:*

Phone:*

Have you had previous psychotherapy?*

No
Yes

Previous therapist's name:*

Are you currently taking prescribed psychiatric medication (antidepressants or others)?*

Yes
No

Please list medications and dosages:*

Who is the prescribing doctor?*

Have you been previously prescribed psychiatric medication?*

Yes
No

Please list medications, length of time taken, and most recent date taken:*

Have you ever been hospitalized for any mental health related concerns?*

Yes
No

Please describe:*

Health and Social Information

How is your physical health at present?*

Please list any persistent physical symptoms or health concerns:*

(e.g. chronic pain, headaches, hypertension, diabetes, etc.)

Occupational Information

Are you currently employed?*

No
Yes

Who is your current employer?*

What is your position?*

How do you feel in your current position?

Please list any work-related stressors:

Family Medical Health History

Has anyone in your family (either immediate family or distant relatives) experienced difficulties with the following?

Family Member(s):*

Additional Information

Please list any additional information I should know about your medical or psychological health history: