NEW CLIENT INTAKE FORM

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Are you currently taking any prescription medication? Have you ever been prescribed psychiatric medication?*

How would you rate your current physical health on a scale from 1-10?*

How would you rate your current sleeping habits on a scale from 1-10?*

Are you currently experiencing overwhelming sadness, grief or depression?*

Are you currently experiencing anxiety, panics attacks or have any phobias?*

Are you currently in a romantic relationship? If yes, for how long? If no, mark "N/A"*

How often do you engage in alcohol/drug use?*

What significant life changes or stressful events have you experienced recently?*

Do you consider yourself to be spiritual or religious?*

Are you currently employed? If yes, what is your current employment situation? Is there anything stressful about your current work?*

What are you looking to accomplish out of your time in therapy?*