Therapy Intake Form

Academic Information
Are you currently in school?

YesNo
Education History
How did you hear about us?

Word of MouthI'm a Former ClientOrder of Psychologists (OPQ)Psychology TodayRate MDsCJAD 800
If Google, using these words
If other, please explain
What is the reason for your visit?
On a scale of 1 to 10 (10 being severe), how intense is your emotion pain?
Please describe
How much do the problems affect your ability to perform at work or school, get along with others, and perform daily tasks such as chores? (5 being Incapacitating)
Please describe
When did these problems start? What was going on in your life at the time?

PSYCHIATRIC AND MEDICAL HISTORY
Please list any psychiatric or mental problems you've been diagnosed with
Please list any physical or medical problems you've been diagnosed with
Please list any medicines you currently take, and what you take them for
Name of Family Doctor

First NameLast Name
Number of Family Doctor
Please enter a valid phone number.Format: (000) 000-0000.
Last check up was during the month of:
Results of Check-up
Name of Psychiatrist

First NameLast Name
Number of Psychiatrist
Please enter a valid phone number.Format: (000) 000-0000.
Last check up was during the month of:
Results of Check-up
MENTAL HEALTH TREATMENT HISTORY
Have you ever been hospitalized for psychological or psychiatric reasons?*

YesNo
Have you ever attended outpatient services in the past?*

YesNo
If so, for how long?
Who was your clinician or clinicians in the past year?
If yes, please describe when and where you were hospitalized and why:
Please tell us about any other mental health professionals you have consulted with in the past (approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment):

Insurance Provider