Intake Form

Personal Information
Name*

Please enter your legal name.
Middle Name
Do you have a preferred first name?*

YesNo
Preferred First Name*
Please enter your preferred first name.
Email*
Please enter a valid email address.
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Gender*

FemaleMaleTransgender FemaleTransgender MaleNon-binaryGender NonconformingPrefer not to answer at this timeOther
Pronouns*

She/HerHe/HimThey/ThemShe/TheyHe/TheyPrefer not to answer at this timeOther
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?*

White (European American)Asian (East)Asian (South)Black (African)Black (African American)Black (Afro-Caribbean)HispanicLatine and/or LatinxIndigenous (North American)Alaska NativeMiddle-EasternIndigenous (Central or South America)First NationsPacific IslanderMultiracial/BiracialNative HawaiianPrefer not to answer at this timeOther
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.*

BIPOC (Black, Indigenous, and People of Color)Part of the LGBTQ+ communityFormerly Incarcerated IndividualVeteranActive Duty MilitaryIndividual with DisabilitiesIndividual in Recovery from Substance UseIndividual with Lived Experience of HomelessnessFirst-Generation ImmigrantFormer Foster YouthI do not identify with any of these thingsPrefer not to answer at this time
Which branch of the military are you/did you serve in?*

ArmyNavyAir ForceMarine CorpsCoast GuardSpace ForceNational GuardOther
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?*

YesNo
Please explain.*
Have you ever been arrested or have any pending legal problems?*

YesNo
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?*

YesNo
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.
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?*

YesNo
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?*

YesNo
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?*

YesNo
Primary Care Physician*
PCP Phone Number*
Please enter a valid phone number.
PCP's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another doctor?*

YesNo
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.
Doctor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another doctor?*

YesNo
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.
Doctor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another doctor?*

YesNo
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.
Doctor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another doctor?*

YesNo
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.
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.
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.*

Depressed MoodUnable to enjoy activitiesIncreased need for sleepExcessive guiltFatigueDecreased libidoIncreased libidoRacing thoughtsImpulsivityExcessive energyIncreased irritabilityCrying spellsExcessive worryDecreased need for sleepLoss of interestDecrease in energyAnxiety attacksAvoidanceHallucinationsSuspiciousnessSuicidal thoughtsForgetfulnessChange in appetiteViolent thoughtsViolence toward othersRisky behaviorSelf-harm
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?*

Physical abuseEmotional abuseSexual abuse as a victimSexual abuse as a perpetratorNeglectWitnessed anyone being abusedHad a family member pass awayExperienced distressful or painful events that still bother you
Please elaborate.*
Have you ever had feelings or thoughts that you didn't want to live?*

YesNo
Do you currently feel that you don't want live?*

YesNo
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?*

YesNo
Would anything make it better?*

YesNo
Do you have a plan to kill yourself?*

YesNo
Is the method you would use readily available?*

YesNo
Is there anything that would stop you from killing yourself?*
Do you feel hopeless and/or worthless?*

YesNo
Have you tried to kill yourself before?*

YesNo
Do you have access to guns, weapons, medications, or anything you can hurt yourself with?*

YesNo
If yes, please explain.*
Medical History
Current height*
Current weight*
Do you have any allergies?*

YesNo
Please list all allergies below.*
Are you currently on any medication or take vitamins and supplements?*

YesNo
Please list all medications, vitamins, and supplements, the dosage, and how often you take each.*
Do you have a uterus?*

YesNo
Are you currently pregnant or think you may be pregnant?*

YesNo
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?*

YesNo
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.*

AnemiaAsthma/respiratory problemsCancerChronic FatigueChronic PainDiabetesEpilepsy or seizuresFibromyalgiaHead trauma/Traumatic Brain InjuryHeart DiseaseHigh blood pressureHigh cholesterolIntellectual or Developmental DisabilityKidney DiseaseLiver Disease/problemsStomach or intestinal problemsThyroid DiseaseMental IllnessOther
If "other," please explain.*
Does anyone in your family have a history of any of the following? Please select all that apply.*

AnemiaAsthma/respiratory problemsCancerChronic FatigueChronic PainDiabetesEpilepsy or seizuresFibromyalgiaHead trauma/Traumatic Brain InjuryHeart DiseaseHigh blood pressureHigh cholesterolIntellectual or DevelopmentalDisabilityKidney DiseaseLiver Disease/problemsStomach or intestinal problemsThyroid DiseaseMental IllnessOther
If "other," please explain.*
Which family members for each illness?*
Have you been hospitalized before?*

YesNo
Date of your last hospitalization.*

MonthDayYear
Date
Please explain what you were hospitalized for.*
Have you had treatment for alcohol or drug use?*

YesNo
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?*

YesNo
Which one(s) and for how long?*
Have you ever abused prescription medication?*

YesNo
Which one(s) and for how long?*
Have you ever had a drink or used drugs first thing in the morning?*

YesNo
Has anyone said that you may have a problem with alcohol or drug use?*

YesNo
Do you think you have a problem with alcohol or drug use?*

YesNo
Do you consume caffeine?*

YesNo
What type(s) of caffeinated beverages and how many of each do you consume each day?*
Do you currently smoke?*

YesNo
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