Intake Assessment rev 07-18-2026

Client Information
Relationship to the Individual Seeking Services
Client's Full Legal Name
Client's Residential Address (include street address, city, state, and zip code)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Contact
May we leave voicemail messages at this phone number?
Parent/Legal Guardian Full Legal Name
Parent/Legal Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Legal Guardian Email Address
example@example.com
Lyra Coverage Information
Are these services covered by LYRA Health?
Who is the eligible member?
Full Legal Name of the Eligible Member

First NameLast Name
Date of Birth of the Eligible Member

MonthDayYear
Date
What Company Does the Eligible Member Work For?
Were you provided with a Lyra code?
Please enter your Lyra code
Section 3: Emergency Contact
Full Name

First NameLast Name
Relationship to You
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Section 4: Primary Care and Other Providers
Primary Care Physician (PCP) Name
Primary Care Clinic or Practice Name
Primary Care Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently working with any other healthcare or mental health providers?
If yes, please list provider name(s), specialty, and practice name.
Section 5: Presenting Concerns and Therapy Goals
What would you most like to accomplish through therapy?
What brings you to therapy at this time?
How long have these concerns been affecting you?
Section 6: Current Symptoms
Which of the following are you currently experiencing?
Section 7: Mental Health History
Have you ever been diagnosed with a mental health condition?
If yes, please list any mental health diagnoses you have received.
Have you previously participated in psychotherapy or counseling?
If yes, please describe your previous therapy experience.
Please include approximate dates, reason for treatment, and whether you found it helpful.
Have you ever received psychological testing or assessment?
If yes, please describe any psychological testing or assessments you have completed.
Have you ever been hospitalized for psychiatric or mental health reasons?
If yes, please describe.
Section 8: Medical History and Medications
Do you have any significant medical conditions?
If Yes, Please Explain
Are you currently taking any prescription medications?
If yes, please list medications and reason for use.
Section 9: Substance Use & Safety Screen
How often do you currently consume alcohol?
How often do you currently use cannabis (marijuana, THC products, edibles, vaping, or related products)?
Do you currently use nicotine or tobacco products?
If yes, what products do you use?
Do you currently use any recreational, non-prescribed, or illicit substances?
If yes, please describe the substance(s) used and frequency of use.
Are you currently experiencing thoughts of harming yourself?
Are you currently experiencing thoughts of ending your life?
If you answered 'Yes' to any of the questions above, please provide additional information.
Have you experienced significant trauma or highly distressing life events that may be relevant to treatment?
If yes, please briefly describe.
Section 10: Social & Occupational History
Current Relationship Status
Current Living Situation
Employment Status
Occupation
Highest Level of Education Completed
Who are the primary people you rely on for support?
Do you feel that you currently have adequate emotional support?
You may share any cultural, spiritual, religious, identity-related, or personal factors that you believe would be helpful for Dr. Goodman to understand when working with you.
Is there anything else you would like Dr. Goodman to know before your first appointment?
Client Acknowledgment*
Should be Empty:

Client Information

Lyra Coverage Information

Section 3: Emergency Contact

Section 4: Primary Care and Other Providers

Section 5: Presenting Concerns and Therapy Goals

Section 6: Current Symptoms

Section 7: Mental Health History

Section 8: Medical History and Medications

Section 9: Substance Use & Safety Screen

Section 10: Social & Occupational History