New Intake Form

Welcome!

All fields marked with * are required.
Thank you for taking the time to fill out our New Patient Form. This is a comprehensive form, and you are not required to fill out the sections past the Contact Information. However, you are encouraged to take the time to complete it, as it will save time at your initial appointment and allow your provider to quickly focus on your needs.

To ensure the security of your data, this system will time out after 90 minutes, and all unsubmitted data will be lost.

Contact Information

Who are you seeing at San Francisco Stress and Anxiety Center*

Client Name*

First NameLast Name

Date Of Birth*

Date

Gender Identity

Preferred Pronouns

Phone Number*

Please enter a valid phone number.

Sex assigned at birth*

MaleFemalePrefer to not disclose

What languages are you fluent in?

What is your ethnicity and/or cultural background

Client Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about SF Stress?*

If other online source please specifiy

Primary Care (or other referring) Physician Please include doctor/hospital name*

If you were referred to us by your doctor or psychiatrist, may we inform them that you are in our care? (This is intended as a professional courtesy only. We will NOT share details of your treatment without obtaining your further consent.)

if you'd like for us to coordinate care with your doctor or psychiatrist, please fill out this Release of Information Form.

Who is your insurance provider?

Please provide the name of your insurance provider (if you have one) even if you are not submitting superbills for reimbursement.

Name*

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

How would you like to be contacted for scheduling and admin matters?*

Please briefly describe the problem(s) that bring you to therapy.*

Have you ever experienced problems like this before? If yes, when?*

Have you experienced any particular source of stress in the last year? If yes, please explain.*

What are your current goals for counseling/therapy? What would be different in your life when counseling is finished? Please be as specific as possible.*

Do you have any concerns or reservations about participating in therapy?*

Are you presently seeing another therapist? If yes, please provide name, phone number, date treatment began, and problem for which treatment was sought.

Have you previously been in counseling, including individual, group, marital, or family therapy? If yes, please provide name of therapist, dates, and reason for seeing them.*

If you have been in therapy, in what way was it helpful?*

If not, in what way was it unsatisfactory?*

Have you ever been hospitalized for mental or emotional difficulties? If yes, when and why?*

Have you ever attempted suicide? If yes, when and how?*

Have you ever taken medications for mental, emotional, or attention difficulties prescribed by a Doctor? If yes, please provide medication name, when they were taken, and for what symptoms.*

Are you currently using any prescribed medications? If yes, please include what medications you are taking, dosage, when started, and prescriber.*

Are you currently facing any legal issues?*

1. Little interest or pleasure in doing things?*

2. Feeling down, depressed, or hopeless*

3. Trouble falling or staying asleep, or sleeping too much*

4. Feeling tired or having too little energy*

5. Poor appetite or overeating*

6. Feeling bad about yourself -- or that you are a failure or have let yourself or your family down*

7. Trouble concentrating on things, such as reading the newspaper or watching television*

8. Moving or speaking so slowly that other people could have noticed. Or the opposite -- being so fidgety that you have been moving around a lot more than usual*

9. Thoughts that you would be better off dead, or of hurting yourself in some way*

10. If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?*

1. Feeling nervous, anxious, or on edge*

2. Not being able to stop or control worrying*

3. Worrying too much about different things*

4. Trouble relaxing*

5. Being so restless that it's hard to sit still*

6. Becoming easily annoyed or irritable*

7. Feeling afraid as if something awful might happen*

8. If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?*

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?*

2. How often do you have difficulty getting things in order when you have to do a task that requires organization?*

3. How often do you have problems remembering appointments or obligations?*

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?*

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?*

6. How often do you feel overly active and compelled to do things, like you were driven by a motor?*

How would you describe your current marital status?*

If you have a partner or spouse, how long have you been together?

Spouse/partner's name (if applicable)

List all children (if applicable) and their names, age, and place of residence

If living, age and health status

If living, where do they live now?

If deceased, year and cause of death

Their occupation (past/and or present)

If living, age and health status

If living, where do they live now?

If deceased, year and cause of death

Their occupation (past/and or present)

Please list all siblings, their name, age, occupation, where they live and if you are in contact with them *

Where did you grow up?*

Did your parents get divorced? *

If yes, when?

Did any biological relatives have any history of psychiatric or emotional problems? If yes, which family members and what types of problems?*

Are you currently working?*

Occupation*

Employer

Do you enjoy your current job?*

Are you currently in school?*

What is your highest degree earned?

Did you ever receive any special education services (e.g. academic tutoring, IEP, classroom accommodations, etc.)? If yes, provide details.*

Do you currently have, or have you had in the past, any serious, chronic, or recurrent heath problems or disabilities? If yes, please describe.*

When was your last physical examination by a doctor? What was the outcome?*

Have you ever used any drugs or medications other than as prescribed? This includes prescription medications, marijuana, amphetamines, barbiturates, cocaine, opiates, Ecstasy, etc.*

Are you currently using? If yes, please describe what type, how often, duration, and method taken.*

If you used any substances listed above, do you feel they caused problems in your work, school, or relationships? If yes, please explain.*

In the past year, how often did you have a drink containing alcohol?*

In the past year, how many drinks did you have on a typical day when you were drinking?*

In the past year, how often did you have six or more drinks in one sitting?*

Have you ever been treated for alcohol or other drug abuse? If yes, please describe.*

Have you ever had a physical fight with a spouse or partner (including throwing objects, hitting, shoving, etc.)?*

Did you ever have sexual contact with someone else without your consent?*

Have you ever experienced or witnessed any traumas (events that felt life-threatening)?*

Have you ever experienced physical or sexual abuse or assault(s)?*

In times of difficulty, who can you turn to for emotional support?

What are your favored activities for relieving stress?

What are your interests and hobbies?

New Intake Form

Emergency Contact

Reasons for coming to therapy

Treatment History

Social & Family Information

Mother's Information

Father's Information

Siblings

Education & Work

General Health

Substance Use

Abuse & Trauma

Strengths