Therapy Intake Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Date of birth:
*
-
Month
-
Day
Year
Date
Please select days you are available.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What is your preffered location?
Murrysville
Robinson
Virtual
N/A
Please select times you are available. Note that reduced availability and evening hours will result in significant wait times to initiate therapy.
Morning
Afternoon
Evening
Reason for Seeking Treatment
*
Current or Past Concerns:
Diagnosis/Concern
Rows
Now
Past
Comments
Depression
Anxiety
Mood Disorder
Anger Management
Bipolar Disorder
Suicidal Ideations or Attempts
Substance Abuse
Paranoia / Hallucination
Schizophrenia
Eating Disorder
Trauma
Emotional/Verbal Abuse
Sexual Abuse
Physical Abuse
Attention Deficit Disorder
Obsessive Compulsive Disorder
Autism
Relationship Distress / Marital Issues
Current Medications:
Rows
Medication
Dosage/Frequency
Condition
Prescriber
1
2
3
4
5
6
7
8
9
10
Medical
Do you have any current physical problems or concerns?
Yes
No
If yes, please specify concerns:
Past or current medical issues:
Medical issues
Rows
Current
Past
Details:
Heart Problems
High or Low Blood Pressure
Stroke
Cancer (Type)
Arthritis
Epilepsy
Diabetes
Anemia
Kidney Problems
Eye / Ear Problems
Liver Conditions
Lung/Breathing Problems
Thyroid Conditions
Sexually Transmitted Disease(s)
Other:
Previous Surgeries:
Yes
No
If yes, specify
Previous Hospitalizations:
Yes
No
If yes, specify:
Submit
Should be Empty: