• Intake Form

  • Date of Birth*
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    2 digit month, 2 digit day, 4 digit year
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  • Insurance Information

  • Birth Date
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    2 digit month, 2 digit day, 4 digit year
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  • Please Select Your Primary Insurance Provider
  • Client Relationship to Insured
  • Client Relationship to Insured

  • In Case of Emergency

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  • PLEASE READ THE FOLLOWING CAREFULLY

  • I understand that I am responsible for my fee payment at the beginning of each appointment. I agree to be responsible for full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. Leslie Rouder, LCSW will honor contractual agreements made with those managed health care companies which stimulate specific reimbursement restrictions.

    I hereby consent to treatment by Leslie Rouder, LCSW. Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I have the right to discontinue or refuse treatment at any time. I understand that I am responsible, however, for any balance due prior to a decision to stop.

    I hereby authorize the release of necessary medical information for insurance reimbursement purposes.

  • Date
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    2 digit month, 2 digit day, 4 digit year

  • Adult Information Form

  • Many managed care companies require that we have interaction with the client's physician to coordinate care. Do you give us the consent to discuss care with the above named doctor?
  • Date of medical evaluation
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    2 digit month, 2 digit day, 4 digit year
  • Next appointment date
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    2 digit month, 2 digit day, 4 digit year

  • Current Symptoms Checklist

  • Current Medication being taken:
    Rows
  • Have you been hospitalized for medical or psychiatric reasons?
  • Rows
  • Do you use recreational drugs?
  • Rows
  • Do you drink alcohol?
  • Rows
  • Do you smoke cigarettes?

  • School and Family History

  • Did you experience any developmental, academic, or behavior problems as a child or while in school, with peers or teachers?
  • Please list schools currently attending, last attended, graduated:
    Rows
  • Please check all information which applies to your biological parents (Mother):
  • Please check all information which applies to your biological parents (Father):
  • List the names and ages of brothers and sisters, including yourself:
    Rows

  • Marital History

  • Marital status:
  • Please list your children:
    Rows

  • Mental Status

  • Please list any of the following that describe how you have been feeling lately:
  • Do you participate in regular exercise?
  • Have you had any change in sleeping habits?
  • Have you had any changes in eating habits?
  • Have you considered suicide in connection to your current problem?
  • Have you ever attempted suicide recently or in the past?
  • Have you had any homicidal thoughts recently or in regard to your current problem?
  • Have you ever considered homicide in the past?

  • Level of Functioning

  • Please check any of the following that apply to you:
    Rows

  • Adult Checklist of Concerns

  • Please mark all the items below that apply, and feel free to add any other items at the bottom under "any other concerns or issues." You may add a note or details in the space next to the check box.
    Rows

  • Signature

  • By signing below I consent that all information provided in this intake form has been answered to the best of my ability. This is a strictly confidential medical record. Redisclosure or transfer is expressly prohibited by law. 

  • Today's Date
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    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: