Welcome to Thrive Psychotherapy
We are committed to supporting you on your path to well-being. Please take a few moments to complete this intake form, which will help us better understand your needs and ensure we provide care tailored to you. Feel free to share any details that you believe are important. A professional will carefully review your responses to match you with the most suitable therapist. Rest assured, all information provided is confidential and will be used solely to enhance your care experience.
Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Gender
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Please Select
Female
Male
Non-Binary
Genderqueer
Genderfluid
Transgender Female
Transgender Male
Two-Spirit
What kind of therapy are you seeking?
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Please Select
Individual Therapy
Couples Therapy
Family Therapy
Group Therapy
Child/Adolescent Therapy
Main Area of Concern
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Main Mode of Therapy
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Please Select
Talk Therapy: Traditional therapy involving conversation with a therapist.
Psychoanalysis: Explores unconscious thoughts influencing behavior.
EMDR: Eye movements used to process trauma and distressing memories.
Brainspotting: Targets trauma by identifying specific eye positions linked to emotional pain.
ERP: Gradual exposure to anxiety triggers, often used for OCD.
CBT: Focuses on changing negative thoughts and behaviors.
DBT: Combines cognitive therapy with mindfulness for emotional regulation.
IFS: Addresses different parts of the self to heal internal conflicts.
ACT: Focuses on accepting thoughts and feelings while committing to values-based actions.
Art Therapy: Uses creative expression to explore emotions.
Play Therapy: Helps children communicate feelings through play.
Somatic Psychotherapy: Integrates body awareness in therapy.
Mindfulness-Based Therapy: Uses mindfulness to reduce stress and improve focus.
Ketamine Assisted Therapy: Combines therapy with ketamine to treat depression or PTSD.
Acupuncture: Holistic approach using traditional Chinese medicine.
Support for Substance Use: Therapy aimed at managing addiction.
Grief Counseling: Support for processing loss and grief.
LGBTQIA+ Affirming Therapy: Supportive therapy focusing on LGBTQIA+ concerns.
Crisis Intervention: Immediate support for acute mental health crises.
Trauma-informed Approach: Therapy grounded in understanding the impact of trauma.
Current Mental Health Concerns
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Anxiety or excessive worry
Depression or persistent sadness
Mood swings or emotional instability
Panic attacks
Trouble sleeping (insomnia or oversleeping)
Difficulty concentrating or focusing
Irritability or anger
Fatigue or low energy
Feeling overwhelmed
Social withdrawal or isolation
Substance use concerns
Obsessive or compulsive thoughts/behaviors
Eating disorders or body image issues
Trauma or PTSD symptoms
Suicidal thoughts or self-harm
Identity concerns (e.g., gender, sexual orientation)
Relationship issues or conflict
Grief or loss
Low self-esteem or feelings of worthlessness
Phobias or specific fears
Sexual concerns or dysfunction
Memory problems or cognitive decline
Guilt or shame
Dissociation or feeling detached from reality
Impulsivity or risky behaviors
Chronic pain or physical symptoms with no clear cause
Difficulty managing daily responsibilities
Loneliness or lack of social support
Financial or job-related stress
Parenting or family-related stress
Cultural or identity-based stress
Challenges with Autism Spectrum-Related Diagnosis
Obsessive Compulsive Disorder (OCD)
Other
Have you ever had feelings or thoughts that you didn't want to live?
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Yes
No
Do you currently feel that you don't want to live?
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Yes
No
How often do you have these thoughts? When was the last time you had thoughts of dying?
Current Therapist / Counselor (if you are seeing someone currently)
First Name
Last Name
Psychiatric History:
Have you ever received a Mental Health Diagnosis?
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Yes
No
If yes, Please describe when, by whom, and nature of treatment
Have you ever received Psychiatric Hospitalization?
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Yes
No
If yes, Please describe when, by for what, and nature of treatment
Medical History
Primary Care Physician (if relevant to your care)
First Name
Last Name
List all current prescription medications (Psychiatric or other) and how often you take them
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Current medical problems
Past medical problems, nonpsychiatric hospitalization, or surgeries
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcohol abuse
Drug Abuse
N/A
Domestic Violence
Other
Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment?
Controlled Substances and Tobacco History
Check if you have ever tried the following
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Fentanol
Other
Please describe your relationship to these substances and frequency of use?
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Have you ever smoked cigarettes? How many packs per day? How many years?
How many caffeinated beverages do you drink a day?
Family Background and Childhood History:
Where did you grow up?
Did your parents divorce?
Yes
No
Were you adopted?
Yes
No
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.
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Exercise Level
Do you exercise regularly?
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Yes
No
Personal History
Highest grade completed?
Are you currently:
Employed
Student
Unemployed
Self Employed
Disabled
Retired
Are you currently:
Married
Partnered
Divorced
Single
Widowed
Other
Do you have any children?
Yes
No
Have you ever been arrested?
Yes
No
Please provide any additional information that may assist us in matching you with the right therapist or that could be helpful in supporting your current care needs.
Emergency Contact
First Name
Last Name
Phone Number
Date
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Month
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Day
Year
By signing below, you acknowledge that the information provided is accurate to the best of your knowledge. You understand that any information shared will be used to support your care and may be shared with your insurance provider or legal guardian as required by law or for billing purposes. Confidentiality will be maintained in accordance with federal and state laws, including specific protections for minors aged 12 and older in Colorado.
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