Clinical Intake Form
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
First Name
Last Name
Email
example@example.com
History of Behavioral Health Services (inpatient, outpatient, etc.)
Please list all of your medications below.
Do you have any medical conditions?
Please tells us about your family.
*
Do you have children? (Name & Age)
Marital Status
Married
Divorced
Single
Widowed
Engaged
Partner
Is Alcohol or Drug Use a problem for you?
Yes
No
How often do you drink/use drugs?
Never
Rarely
Sometimes
Often
Do you have a history of legal offenses (which ones & what year)?
Have you ever been told to you should cut back?
Yes
No
How long have you been using?
Do you have any concerns that we can help you with?
Alcoholism
Legal Issues
Work/School
Drug Abuse
Grief
Anger
Depression
Divorce
Suicidal Ideas
Bi Polar
Addiction
Unemployment
Trauma
Self Esteem
Relationship Issues
Codependency
Abuse
Divorce
Other
Please give us some detail about how we can help.
Submit
Should be Empty: