MINDFUL IN RECOVERY

INITIAL INTAKE

Gary A. Delpine, LCDC, AADC, CART
DATE

MonthDayYear
Date
NAME*

First NameLast Name
PHONE NUMBER*
Please enter a valid phone number.
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH*

MonthDayYear
Date
EMAIL ADDRESS*
example@example.com
MARITAL STATUS*

SingleMarriedDivorcedWidowed
EMERGENCY CONTACT*

NAME

RELATIONSHIP

RELATIONSHIPPHONE NUMBER
NUMBER OF CHILDREN
CHILDREN INFORMATION
EMPLOYMENT INFORMATION
REFERRED BY (if applicable):*

NamePhone Number
REASON FOR SEEKING COUNSELING:*
PREVIOUS TREATMENTS/COUNSELING STARTING WITH MOST RECENT:
DRUGS OF PATHOLOGICAL USE AND/OR ALCOHOL:
CURRENT MEDICATIONS*
PHYSICAL HEALTH (ANY CURRENT CONDITIONS OF CONCERN):*
ARE YOU CURRENTLY FEELING DEPRESSED OR BEING TRERATED FOR DEPRESSION?*
DO YOU CURRENTLY HAVE OR HAVE YOU EVER HAD THOUGHTS OF SELF-HARM OR SUICIDE?*
INITIAL ASSESSMENT & INDIVIDUAL THERAPY SESSION
(ONE HOUR) - $130.00

Patient authorizes Mindful in Recovery, Inc. to charge $130.00 for an initial one-hour assessment and/or individual therapy session. I understand that there is a 24-hour cancellation requirement. If 24-hour notice of cancellation is not given prior to scheduled appointment, the fee for session will be charged.
PATIENT NAME*

First NameLast Name
DATE*

MonthDayYear
Date
Patient Signature*

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Should be Empty:

INITIAL INTAKE