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
Cell Phone
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
Is my Information safe?

This form has encryption enabled. This further safeguards sensitive information in your form. End-to-end encryption is a security measure that guarantees privacy by encrypting your form data when users fill and submit it.

In addition, several other measures are in place to protect your privacy. Learn More here:https://www.jotform.com/security
Should be Empty:

Session Intake Form

Medical History

Mental Health History