Intake Form

  • Intake Form

  • Date of Birth*
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  • Insurance Information

  • Birth Date
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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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  • 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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  • Next appointment date
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  • Current Symptoms Checklist

  • Rows
  • Have you been hospitalized for medical or psychiatric reasons?
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  • Do you use recreational drugs?
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  • Do you drink alcohol?
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  • 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?
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  • Please check all information which applies to your biological parents (Mother):
  • Please check all information which applies to your biological parents (Father):
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  • Marital History

  • Marital status:
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  • 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

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  • Adult Checklist of Concerns

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  • 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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  • Should be Empty: