MINDFUL IN RECOVERY

INITIAL INTAKE

Gary A. Delpine, LCDC, AADC, CART
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
NAME

First NameLast Name
PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
EMAIL ADDRESS
example@example.com
MARITAL STATUS
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
2 digit month, 2 digit day, 4 digit yearDate
Patient Signature
Should be Empty:

INITIAL INTAKE