New Client Intake
Please provide the following information and answer the questions below. Information you provide here is protected as confidential information.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
May we leave a message?
Please Select
Yes
No
Birth Date
-
Month
-
Day
Year
Date
Email
example@example.com
Referred by (if any)
Which most closely describes your gender?
Please Select
Woman
Man
Transgender Woman
Transgender Man
Non-binary
Agender
Prefer not to state
What brings you to therapy?
Have you previously received any type of mental health services?
No
Yes
Are you currently taking any prescription medication?
No
Yes
If yes, please list:
General Health and Mental Health Information
How would you rate your current physical health?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any specific health problems you are currently experiencing:
How would you rate your current sleeping habits?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
How many times per week do you generally exercise? What type of exercise do you participate in?
Are you currently experiencing overwhelming sadness, grief or depression?
No
Yes
If yes, for approximately how long?
Are you currently experiencing anxiety, panic attacks or having any phobias?
No
Yes
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain?
No
Yes
If yes, please describe:
How often do you drink alcohol?
How often do you engage in recreational drug use?
What significant life changes or stressful events have you experienced recently?
Family Mental Health History (please check any of the following that apply)
Alchohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorder
Obesity
Obsessive/Compulsive Behavior
Schizophrena
Suicide Attempt
Abuse
Submit
Should be Empty: