Patient Information Intake

Patient Information Intake

This form collects essential patient information to help Carolyn Cole, Psy.D., LLC, better understand your background, current concerns, and treatment needs. By completing this form, you provide details that enable the development of an informed and personalized treatment plan. Please review and fill out all sections carefully, and acknowledge receipt of the HIPAA Notice of Privacy Practices by signing below.
Name*
Age*
Date of Birth*

MonthDayYear
Date
Phone*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Is your occupation...

CurrentRetired
Relationship Status

MarriedWidowedDivorcedSingleCo-habitatingOther
Children
Stepchildren
Emergency Contact Name*
Emergency Contact Phone*
Emergency Contact relationship to you*
What are the reasons for seeking treatment?*
Are you currently in any other treatments to address mental health concerns or wellness (i.e. medication management, group therapy, support, chiropractic, acupuncture, etc.)? If yes, please specify:*
If you are currently taking medication for mental health issues (i.e. mood, anxiety, sleep, focus), please specify name of medication, for what condition, dosage, start date (approx.):*
Prescribing Psychiatrist or Physician:
Prescribing Psychiatrist or Physician's Contact Information:
* You signature below acknowledges that you have received a copy of the HIPPA Notice of Privacy Practices.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: