Intake Form
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Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
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Postal / Zip Code
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Afghanistan
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Gender
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Cell Phone
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Home Phone
May we leave a message on your cell?
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May we email you?
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Email
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Are you currently employed?
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Occupation
Birth Date
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Month
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Day
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2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
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1926
1925
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1921
1920
Year
Marital Status
Please Select
Single
Married
Divorced
Separated
Widow(er)
Spouse's Name
Emergency Contact Phone Number
*
How were you referred to Trauma Referral Consultants?
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General Medical History
Please list any specific health problems you are currently experiencing:
Do you exercise? If so, what type and how many times per week?
Have you been diagnosed with an eating disorder or have any unusual eating patterns?
Are you currently experiencing any chronic pain?
Yes
No
Have you (currently or in the past) been prescribed psychotropic medication?
Yes
No
If you answered "yes" to the above question, please list the name of the medication(s) and dosage:
Are you currently being treated by a psychiatrist?
Yes
No
Have you in the past (or currently) used recreational drugs?
Yes
No
If you answered "yes" to the above question, please list drug(s), frequency and date of last use:
Do you drink alcohol?
Never
Once a month
Several times a month
Once a week
Several times a week
Daily
Have you ever been hospitalized?
Yes
No
If you answered "yes" to the above question, please describe the reason:
Do you smoke cigarettes?
Yes
No
Have you ever had surgery?
Yes
No
If you answered "yes" to the above question, please describe the reason:
Have you ever had chemotherapy?
Yes
No
If you answered "yes" to the above question, please describe the reason:
Have you ever had a concussion?
Yes
No
If you answered "yes" to the above question, please describe the reason:
General Mental Health Information
What is the main reason you are seeking treatment?
What gives you the most pleasure in life?
What are you main worries and fears?
What are your hopes and dreams?
Do you have a history of sexual, physical or emotional abuse?
Yes
No
If you answered "yes" to the above question, please explain:
Have you ever attempted suicide?
Yes
No
If you answered "yes" to the above question, please explain:
Do you meditate?
Never
Once a month
Several times a month
Once a week
Daily
Twice daily
Have you ever had a near death experience?
Yes
No
If you answered "yes" to the above question, please explain:
Have you recently lost a loved one?
Yes
No
If you answered "yes" to the above question, please explain:
(For women) Have you given birth that was stressful beyond the ordinary?
Yes
No
If you answered "yes" to the above question, please explain:
Do you have any specific spiritual or religious practice?
Yes
No
If you answered "yes" to the above question, please explain:
Please mark if you have had any of the following treatments? (Please check all that apply)
Psychotherapy
Hypnotherapy
Acupuncture
Reiki/hands on healing
Body work (shiatsu, reflexology)
Homeopathy
Chinese Medicine
Cranio-scaral therapy
Shamanic healing
Please list any other therapies you experienced:
Are you experiencing any of the following? (Please check all that apply)
Anxiety
Depression
Anger
Alcoholism
Stress
Drug Addiction
Communication Issues
Eating Disorder
Parenting Issues
HIV Positive
Adoption Issues
Abandonment Issues
Post Traumatic Stress Disorder
Other
If you answered "yes" to the above question, please explain:
Is there a family history of any of the following? (Please check all that apply)
Anxiety
Depression
Anger
Alcoholism
Stress
Drug Addiction
Sexual Abuse
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Disorders
Suicide
Schizophrenia
Communication Issues
Parenting Issues
HIV Positive
Adoption Issues
Abandonment Issues
Post Traumatic Stress Disorder
Other
Have you been treated for any health conditions in the last year?
Yes
No
If you answered "yes" to the above question, please explain:
List any other health problems, no matter how insignificant they may seem:
Do any of your family members suffer from these? (Please check all that apply)
Anxiety
Depression
Anger
Alcoholism
Stress
Drug Addiction
Communication Issues
Eating Disorder
Parenting Issues
HIV Positive
Adoption Issues
Abandonment Issues
Post Traumatic Stress Disorder
Other
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