Intake

Transformative Therapy Jacqueline Bocian, M.A., L.C.S.W., License #80469

INDIVIDUAL INFORMATION - INTAKE FORM

Please complete this intake form. Upon submission, it will be sent to me directly and you will receive a copy in your inbox. This will help me get to know you as we begin working together. All information is strictly confidential.
Name
Gender
Date of Birth

MonthDayYear
Date
Marital Status
With whom do you live? (Names, Ages. Relationships)
Home Address
Home Phone #
Work Phone #
Cell Phone#
Confidential messages should be left at which phone number?
Email Address: #
example@example.com
Emergency Contact Name
Phone Number
Medical Doctor(s)
Current or Previous Medical Issues
Current Medications
Significant Family Medical History
Significant Family History of Mental Illness or Addiction
Please check any of the following that apply:

HeadacheHigh blood pressureGastritis or esophagitisHormone-related problemsHead injuryAngina or chest painIrritable bowelChronic painLoss of consciousnessHeart AttackBone or joint problemsSeizuresKidney-related issuesChronic fatigueDizzinessFaintnessHeart valve problemsUrinary tract problemsFibromyalgiaNumbness & tinglingShortness of breathDiabetesHepatitisAsthmaArthritisThyroid issuesHIV/AIDSCancerOther
Alcohol use (frequency and amount)
Recreational drug use (type. frequency and amount)
Do you have suicidal thoughts?

YesNo
Have you ever attempted suicide?

YesNo
If you answered yes to the question above, please provide details
Have you had therapy before? (circle one)

YesNo
If you answered yes to the question above, please provide name of previous therapist(s)
What are your main reasons for seeking therapy? Please be as specific as you can.
What are the main goals you wish to achieve in therapy? Please be as specific as you can.

Please select and rate any of the following symptoms you have experienced in the past 12 months:

	Mild	Moderate	Severe	For how long?
Increased appetite
Decreased appetite
Trouble concentrating
Hopelessness
Nightmares
Difficulty sleeping
Excessive sleep
Obsessive thoughts
Phobias
Anger
Low motivation
Fatigue/low energy
Low self-esteem
Depressed mood
Suicidal thoughts
Anxiety
Fear
Panic attacks
Sexual problems

Education (highest level attained)
Current occupation
Previous occupation(s)
Current legal issues, including divorce/custody matters
What brings you the most joy and pleasure in life?
What are your main worries and fears?
What additional information would you like me to know about you?
Please share who referred you.
Should be Empty: