MFD Intake Form

Client Intake Form

My Favorite Day, PLLC
Personal Information
Full Name*

First NameLast Name
Preferred Name

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Birth Date*

MonthDayYear
Employer
Occupation
Partner Status
Partner's Name
Emergency Contact
Emergency Contact Phone Number
Primary Care Provider
Primary Care Provider Phone Number
How were you referred to our office?

Internet SearchPsychology Today ProfileFrom a Friend or ColleagueReferral from DoctorOther
You can add the name of who referred you here:

Financial Information
How I plan to pay for treatment:*

I plan to use my insurance benefitsI plan to be private payI am part of the APD Victim Crime Services

History of the Present Problem
What brings you to therapy at this time?*
What are your goals for therapy?*
Have you ever had the same or a similar problem?

YesNo
Have you been to therapy before?

YesNo
Did it help?

YesNo
If yes, please say what was helpful about it:
If no, please say what was not helpful about it:
Are you having any thoughts of suicide or harming yourself?

YesNo
If yes, please describe:
If you are currently having any thoughts of self harm or suicide it's important that you seek immediate crisis intervention or sicide prevention services. For immediate assistance, dial 911 or go to your local emergency room. you can also reach out to the following resources:

- Call 988 Suicide and Crisis Hotline

- Website: https://988lifeline.org/

- If you prefer, you can text HOME to 741741 to connect with a Crisis Counselor.

Please note this therapist is not a crisis hotline. This intake form will be reviewed by your therapist but may not be immediately reveiwed at the time of submission. It is important that if you are in imminenet risk of suicide that you contact the resources provided.

Signature and Submission
Patient's Signature*
Date*

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature
Enter the message as it's shown*

Should be Empty: