THERAPY REFERRAL/INTAKE FORM (2)

THERAPY REFERRAL/INTAKE FORM
Demographic Information

Patient/Client Details
Name *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Sex: *
Ethnicity: *
Parent/Guardian Name (if applicable): *
Insurance Provider
Contact Information
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email: *
example@example.com
Phone Number *

Area Code Phone Number
Referring Provider Information
Referring Provider (if applicable):
Referring Provider Phone Number

Area Code Phone Number
Referring Provider Email:
example@example.com
Presenting Issue(s)/Concern(s): *
Have symptoms recently worsened? *

Yes No
If, yes, please briefly describe.
Please indicate if psychological services are required (e.g., court-ordered, work or school program, etc): *
Past/Current Diagnoses: *
Current Treatments - medications, therapy, etc.: *
Briefly describe how well past/current treatments have worked (e.g., partial symptom relief, extensive progress with need for maintenance support, emergence of new symptoms, etc.) *
Any past or current suicidal ideation *

Yes No Unknown
If, there has been any history of suicidal ideation please provide a brief summary.
Any past or recent psychiatric hospitalizations *

Yes No Unknown
If yes, please briefly describe the reason for hospital admission, length of stay, and discharge plan. *
What are the hopes/goals for treatment? *
Please provide any additional information pertinent to this referral.
*Deeper Insights/Dr.Stubbs will primarily utilize email to communicate. Be sure to check email regularly including spam folders.*
Should be Empty:

THERAPY REFERRAL/INTAKE FORM

Demographic Information

Contact Information

Referring Provider Information