Client Intake Form
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Name
*
First Name
Middle Initial
Last Name
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Age
*
Social Security Number
*
Don't include dashes
Cell Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Married / Single / Divorced
Emergency Contact
First Name
Last Name
Relationship to patient
Contact Phone Number
-
Area Code
Phone Number
Contact Email
example@example.com
Driver's License Number
State
Primary Care Physician
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Treating Specialist Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Primary Insurance Company
Primary Insurance ID
Secondary Insurance Company
Secondary Insurance ID
Relationship to Insured
Who may we thank for referring you?
*
Briefly describe your reason for coming here
*
List previous psychiatric or counseling treatment, problems treated, providers, and approximate dates:
*
If you have no prior treatments, type (not applicable) in box
Please list all current medication(s) and dosage
*
If you have no medications, type (not applicable) in box
What significant life changes or stressful events have you experienced recently?
*
Please describe what you wish to accomplish in therapy
*
Is there anything else we should know?
Send to Dr. Eimer
Should be Empty: