Intake information

Personal Information
Name

First NameLast Name
I prefer to be called:
Birth Date*

MonthDayYear
Place of birth
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Email Address*
Emergency Contact Name & Phone*
Relationship Information
Marital Status:

SingleMarriedDivorcedWidowedSeparatedDomestic Partner
How many times have you been married?
How many significant relationships outside of marriage?
Estimated number of sexual partners
Length of current relationship
Divorced or widowed how long?
Partner's Name
I would describe my marriage as: (Choose one unless you answer "abusive" then choose one other descriptive category)

As near to perfect as one can hope to haveHappyGoodFriendlyFairUnhappyAbusiveOn the edge of ruin
Additional Information about your relationship(s):
Children
Please list Children & step-children's names and ages
Vocation
Work Status

EmployedUnemployedRetiredFired or asked to resignPart timeOther
Occupation
Employer

Job Satisfaction

	1	2	3	4	5	6	7	8	9	10

1 is Need change badly, 10 is Love it

Medical History
PCP Name
PCP Phone Number
PCP Fax #
Date of Last Physical Exam
Do you use tobacco in any form?

YesNo
If yes, please list type, amount, and frequency of use
Please list any other mood altering substances you use (caffeine, marijuana, etc...)
Do you use Alcohol in any form?

YesNo
If yes, please list type, amount and frequency of use
e.g. "2 beers every night"
Are you taking any medication? If yes, please list medication and dosage per day
Last therapist's name
How long did you see them?
Date of last therapist visit
Therapist Phone #
Symptomology: Please check all that apply

Regular headaches / migrainesSleeplessness (long term)Sleeplessness in current crisisMajor appetite changeHeart problemsHigh blood pressureHeartburn (acid reflux)Fainting spellsCancer diagnosisDiagnosed with anxietyDiagnosed with depressionDiabeticBack and / or neck painFybromyalgiaHypertensionPanic AttacksErectile DysfunctionGenito Pelvic PainAnorexiaBulimiaInability to focusAlcohol AbuseDrug AbuseLeg or foot painCutting or self harmLibido ChangesAnxietyCrying SpellsExcessive energyFatigueDepressionIrritabilityHallucinationsImpulsivityGuiltShameRacing thoughtsRisky BehaviorsSuspiciiousness of othersAppetite IssuesAvoidance of people or tasks
Background information
Name and Ages of all siblings
Family history

Alcoholism in familyAddiction in familyPsychiatric or psychological issues in family historyDivorce in familyRaised in povertyRaised in Middle classRaised in affluenceViolence in homeSexual abuseFather was a strict disciplinarianMother was a strict disciplinarianMother diedFather diedsibling diedSpanking was the primary punishment in our familyThere was lots of verbal fighting in my home growing upThere was lots of worry in my home growing upMy family said "I love you" a lotMy family never said, "I love you."My parents were proud of meMy parents regretted having meMy parents expressed affection for one another frequentlyAffection was rarely or never expressed in my home
Reason for appointment
I asked to see you because:
Does this come from

Something that happenedAn ongoing situation
This first became an issue...
My goals
Up to five things I want from engaging Gracefall are:
If applicable: "I wish my spouse or partner knew..."
This will be held in strictest confidence and not shared with anyone
Should be Empty:

Personal Information

Relationship Information

Children

Vocation

Medical History

Background information

Reason for appointment

My goals