Date
*
/
Month
/
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Initials
*
Initials
*
Initials
*
Initials
*
Initials
*
Initials
*
Initials
*
Long Text
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Single Choice
Yes
No
Phone Number
Format: (000) 000-0000.
Address
Short Text
Signature of Parent or Guardian
*
Date
*
/
Month
/
Day
Year
Date
Client Signature
*
ParentGuardian Name
Client Name
Resource and Positive Impact History Please share people activities or things that have supported and affirmed you in your life in the past and present
If you have children list your childbearing or childraising history
Are you taking any medications overthecounter or prescriptions Please list below
Have you been diagnosed treated or hospitalized for mental health issues Please explain Include any current treatments and relevant dates
Do you have a history of depression andor anxiety Please explain Include any treatments that you find supportive
Do you have any history of surgeries including dental Please explain
Please explain any of the above or other conditionssymptoms you have experienced
Emergency contact
Referred by
Email
*
example@example.com
Cell
Gender
DOB
Name
INTAKE FORM
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