Therapy Intake Form

Therapy Intake Form

Welcome!
Name*

First NameLast Name
Email*
example@example.com
Phone*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Preferred Method of Contact*

E-mailHome PhoneCell Phone
I am looking for....*

A therapist just for meCouples TherapyTherapy for one or more of my childrenTrauma Informed YogaOther
I prefer to meet*

In personOnlineI'm flexible
Qualities I look for in a therapist include...

A sense of humorSomeone who listens without interruptionSomeone who challenges meSomeone who is a good problem solverSomeone who provides structureSomeone who gives good feedbackSomeone involved in the LGBTQ+ communitySomeone who has a positive outlookSomeone who is nurturing
How did you hear about us?*

I am a returning clientWord of mouthGoogleA family member or friendSchool systemSocial mediaPsychology TodayMy insurance companyMy providerOther
If you were referred by your PCP, what is their name?*
Insurance Information
Name of Insurance (if None write N/A)*
Name of Policy Holder*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Member ID*
Group Number*
Medical History
Do you use alcohol?*

NoDailyWeeklyLessFormer User
Caffeine use?*

NoDailyWeeklyLessFormer User
Are you currently taking prescription medication?*

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone
Mental Health History
Why you are seeking treatment?*
Days/times you are available*
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?*

YesNo
Are you a veteran or an active member of the military?**
Do you have a history within the last 6 months of suicide attempt?*
Are you currently involved in any legal disputes?*
Are you currently in a household that is experiencing domestic violence?*
*Domestic Violence is a condition that requires special care and expertise. Please let our Intake Specialist know if your are currently in a situation where you are experiening DV or if you are at risk of DV so they can do their best to help you find the right services.
If you are seeking services for your child, please describe the marital and custody status of the child's parents. Is DCF involved?:**
Tell us a little about you, and your situation to help us match you with the right person:*
Additional comments or concerns
Should be Empty:

Therapy Intake Form

Insurance Information

Medical History

Mental Health History