Intake Form

Personal Information
Name

Please enter your legal name.
Middle Name
Do you have a preferred first name?
Preferred First Name
Please enter your preferred first name.
Email
Please enter a valid email address.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Gender

Other
Pronouns

Other
Please upload a picture of your identification card.

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Please upload a picture of your social security card.

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Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In what city/town did you grow up?
In which state did you grow up?
If you selected "other," please enter the country, if outside of the US, or state where you grew up.
What is your preferred language?
If you selected "other," what is your preferred language?
What is your religious preference?
If other, what if you religious preference?
Which option(s) best describe your racial identity?
At Seeds of Renewal, we are committed to creating a welcoming and inclusive environment for all individuals on their journey to healing. To help us better understand and support our community, please select any of the following that you identify with.
Which branch of the military are you/did you serve in?
If other, please explain.
What is your highest level of education?
What is your reading level?
What is your writing level?
Do you need assistive technology or an interpreter?
Please explain.
Have you ever been arrested or have any pending legal problems?
Please explain.
Which of the following best describes your current employment status?
If applicable, please provide details about your current or past employment, including your workplace and job role.
Which of the following best describes your relationship status?
How long have you been in your current or past significant relationship (in a relationship, married, partnered, divorced, or widowed), and how would you describe your relationship?
Do you have any children?
Please explain your family situation regarding your children, including how many you have, where they currently live, and your custody status.
Emergency Contact
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
If you selected "other," what is the relation to your emergency contact?
Insurance Information

Please complete the following section to the best of your ability.
Please upload a picture of your insurance card.

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Do you have insurance information to provide?
Primary Insurance
Policy Number
Group Number
Policy Holder
Relationship to Policy Holder
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a secondary insurance?
Secondary Insurance
Policy Number
Group Number
Policy Holder
Relationship to Policy Holder
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physicians & Pharmacies
Do you have a primary care physician?
Primary Care Physician
PCP Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PCP's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another doctor?
What type of doctor?
If you selected "other," please enter your doctor's specialty.
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another doctor?
What type of doctor?
If you selected "other," please enter your doctor's specialty.
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another doctor?
What type of doctor?
If you selected "other," please enter your doctor's specialty.
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another doctor?
What type of doctor?
If you selected "other," please enter your doctor's specialty.
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Pharmacy
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Wellness Intake
Why are you seeking treatment at this time?
What do you hope to gain from treatment? What would you like to be different?
What do you like about yourself? What are your personal strengths?
What are your interests and hobbies?
What is important to you?
What helps you to feel calm?
What are your current symptoms? Please check all that apply.
If you selected "risky behavior," please explain.
If you selected "self-harm," please explain.
If you selected "violence toward others," please explain. Anyone specifically?
Have you experienced any of the following?
Please elaborate.
Have you ever had feelings or thoughts that you didn't want to live?
Do you currently feel that you don't want live?
How often do you have these thoughts?
When was the last time you had thoughts of dying?
Has anything happened recently to make you feel this way?
Would anything make it better?
Do you have a plan to kill yourself?
Is the method you would use readily available?
Is there anything that would stop you from killing yourself?
Do you feel hopeless and/or worthless?
Have you tried to kill yourself before?
Do you have access to guns, weapons, medications, or anything you can hurt yourself with?
If yes, please explain.
Medical History
Current height
Current weight
Do you have any allergies?
Please list all allergies below.
Are you currently on any medication or take vitamins and supplements?
Please list all medications, vitamins, and supplements, the dosage, and how often you take each.
Do you have a uterus?
Are you currently pregnant or think you may be pregnant?
What was the date of your last menstrual cycle?

MonthDayYear
Date
Do you have any concerns about your physical health that you would like to discuss with us?
What was the date of your last physical exam?

MonthDayYear
Date
Do you have a history of any of the following? Please select all that apply.
If "other," please explain.
Does anyone in your family have a history of any of the following? Please select all that apply.
If "other," please explain.
Which family members for each illness?
Have you been hospitalized before?
Date of your last hospitalization.

MonthDayYear
Date
Please explain what you were hospitalized for.
Have you had treatment for alcohol or drug use?
In the past 3 months, what is the largest amount of alcohol you have consumed in one day?
Have you used street drugs in the last 3 months?
Which one(s) and for how long?
Have you ever abused prescription medication?
Which one(s) and for how long?
Have you ever had a drink or used drugs first thing in the morning?
Has anyone said that you may have a problem with alcohol or drug use?
Do you think you have a problem with alcohol or drug use?
Do you consume caffeine?
What type(s) of caffeinated beverages and how many of each do you consume each day?
Do you currently smoke?
Please list the kinds (e.g. cigarettes, cigars, etc.), how long you have been smoking (e.g. years), and how often each day of each.
Outreach & Awareness
Who helped you complete this form, if anyone? Please select 'Self' if you completed it on your own.
How did you hear about us?
If other, please tell us how you heard about us.
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Personal Information

Emergency Contact

Insurance Information

Physicians & Pharmacies

Wellness Intake

Medical History

Outreach & Awareness