Comprehensive Intake Form

New Patient Intake Form

5-7 minute completion time.
Name*

First NameLast Name
Preferred Phone*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Is the patient a minor?*

YesNo
Are both Parents required to consent to treatment by law?*

YesNoNot applicable
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Whom may we thank for you referral?*

Insurance App/websiteDoctor or other specialistSearch Engine (Google, Yahoo, etc.)Other
If you were referred by a Doctor or Provider, please list them below
Sex Assigned at Birth*

MaleFemalePrefer not to respond
Gender Identity
Sexual Orientation
Preferred Language
Preferred Name
Ethnicity
Race
Religion (If Applicable)
Provider Preferences*
Scheduling Preferences*
Insurance
Name of Primary Insured (Subscriber)*
Subscriber Date of Birth*

MonthDayYear
Date
Insurance Company (Primary Insurance)*
Insurance ID # (Primary Insurance)*
Group # (Primary Insurance)
Policy Start Date (Primary Insurance)
Policy End Date (Primary Insurance)
Marital Status
Name of Spouse (If Applicable)
Age of Significant Other (If Applicable)
Briefly describe your relationship with current spouse/significant other (if applicable)
Emergency Contact or Parent Name*
Emergency Contacts Relationship*
Emergency Contact or Parent's Phone Number*
Format: (000) 000-0000.
Briefly state why you are seeking treatment at this time. (Important for Placement)*
Services Requested (Check All That Apply)*

Counseling/TherapyMedication ManagementPsychological TestingGifted Testing
If Counseling, Which Services? (Check All That Apply)

Individual CounselingCouples CounselingFamily Counseling
If Couples or Family's Counseling is being requested, Please note that an intake form will need to be submitted for each individual.**
Please note any significant physical medical history and or non-psychiatric hospitalizations. (Required)
Please note any food or medication allergies.
Is the Patient pregnant, or post-partum by less than six weeks?

YesNo
Does the patient have a history of drug/alcohol use?

YesNo
If drug/alcohol use is current, please state the frequency of use.
Has treatment been received for drug/alcohol use?

YesNo
Please detail when, by whom, and the nature of the treatment
Is there a history of physical or sexual abuse?
Is there a history of physical or sexual abuse? (Required)

Yes, PhysicalYes, SexualYes, BothNo
At what point in time did this abuse occur?
Has outpatient mental health treatment/psychotherapy/counseling been completed previously?

YesNo
Please detail when, by whom, and the nature of the treatment.
Has the patient experienced any psychiatric hospitalizations? (Required)

YesNo
Please detail when, by whom, and the nature of the treatment.
Is the patient currently taking, or have ever taken, any psychiatric medications? (Required)

YesNo
Please detail any psychiatric history.
Is there any history of suicidal thoughts, threats, or attempts? (Required)
Please list the dates and/or frequency of these events:
Pharmacy Name
Pharmacy Phone Number
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are the Parents deceased? If so, please state below which parent and how old.
Are the caregivers divorced?

YesNo
During pregnancy, did the birth mother use drugs or alcohol?

YesNo
During pregnancy or birth, were there any complications?

YesNo
Please detail the complications:
Birthplace
How would you describe academic performance during childhood?

ExcellentAveragePoor
If poor, explain:
Highest Level of Education
Currently a student?

YesNo
If Yes, Where?
Employment Status?
Occupation? (If Applicable)
Who is the employer? (If Applicable)
Are you a member of law enforcement, a first responder, or military personnel?

YesNoPrefer not to respond
Is there a history of arrests?

YesNoPrefer not to respond
Should be Empty:

New Patient Intake Form

Insurance

If Couples or Family's Counseling is being requested, Please note that an intake form will need to be submitted for each individual.**