Session Intake Form

Session Intake Form

Please complete this form after booking your 1-on-1 Session
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Referred By

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Preferred Method of Contact

E-mailHome PhoneCell Phone
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Are you currently taking prescription medication?

YesNo
Have you had any surgeries in the past 5 years?

YesNo
Please specify:
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
Mental Health History
Why you are seeking treatment?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
Date

MonthDayYear
Date
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Session Intake Form

Medical History

Mental Health History