Please Read Before Proceeding

Release it Counseling Intake Form

You Must complete as the first step to schedule an appointment. Please make sure you slide this form up to see the entire form. As you cannot slide the page to slide up the form. This Form can be saved and continued for later.
Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Is your primary language English*

YesNo
Please select the state that you will be located in for therapy*
City*
Please describe your presenting problem? *
Briefly describe what you need from your therapist to help you be successful in therapy? Ex; honesty, support, promptness etc.*
Briefly describe what you want to achieve in therapy?*
Who would you say your present support system is? ex; friend, spouse, colleague etc.
Current Symptoms*

Depressed moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncrease risky behaviorAvoidanceLoss of interestIncreased libidoHallucinationsConcentration/forgetfulnessDecrease need for sleepSuspiciousnessChange in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spellsDecreased libidoHearing voicesDelusionsOther
Have you ever had feelings or thoughts that you didn't want to live?*

YesNo
Do you currently feel that you don't want to live?*

YesNo
Do you have or ever had a plan on how to commit suicide?*
How often do you have these thoughts?
When was the last time you had thoughts of dying? Please put "NA" if this question doesn't pertain to you.*

Please answer the below questions*

	Yes	No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?
Do you battle with extreme anger?
My emotions change very quickly, and I experience intense episodes of sadness, anger or irritability?
My level of anger is often inappropriate or difficult to control?
I engage in frantic efforts to avoid real or imagined abandonment by those close to me?
I have a significant and persistently unstable image of myself?
Have any of your closest relationships been troubled by a lot of arguments or repeated breakups?
Have you often been distrustful of other people
Have you often felt that you had no idea of who you are or that you have no identity

Current medical problems
Psychiatric History:
Have you been to therapy before?*

YesNo
Please select if you've ever been diagnosed with any of the below*

SchizophreniaBorderline Personality DisorderDissociative identity disorder- DIDNone of the Above
Please list all previous mental health diagnoses. If none put "NA"
Have you ever been placed in Psychiatric Hospitalization*

YesNo
If yes, Please describe when, by whom, and nature of treatment
Have you been seen by a psychiatrist/NP/PA/MD in the last year (365 days)?

YesNo
You Must answer, If you answered yes to the previous question please list the providers and last date seen here
Past Psychiatric Medications

If you have ever taken any of the following medications?*

	Have you ever taken it?
Select this option if you've Never taken any psychotropic medications
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)

Has anyone in your family been diagnosed with or treated for:*

Bipolar disorderDepressionAnxietyAngerSuicideSchizophreniaPost-traumatic stressAlcoholabuseOther
Check if you have ever tried or used any of the following substances?*

Never used any illegal substancesMethamphetamineCocaineStimulants (pills)HeroinLSD or HallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizer/sleeping pillsAlcoholEcstasyOther
Have you used any substances in the last 6 months?*

YesNo
Are you presently using any Substances?*

YesNo
Please list you present Substance of choice.
Are you seeking Substance abuse treatment?

YesNo
Do you presently smoke cigarettes?

YesNo
Personal History
Have you experienced any trauma; domestic violence, sexual abuse, child abuse?*

YesNo
Are you currently:

MarriedPartneredDivorcedSingleWidowed
Are you seeking Couples counseling? COUPLES COUNSELING NO LONGER OFFERED

YesNo
Only answer if you are seeking couples counseling with INSURANCE PAYMENT. Please list the name of each of your individual therapist, and the last date that each of you attended your individual counseling.
Spouses Name

First NameLast Name
Spouses Date of Birth
Spouses Email
example@example.com
Insurance Information
Please upload a copy of your Medical Insurance card front and back; you will have to upload two images. If you do not have a copy of your insurance you will have to input manually on next screen.

Browse Files

Cancelof
Please Select your Insurance Provider*
Insurance ID*
Policy Holders Name

First NameLast Name
Policy Holders Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Policy Holder
Do you have Medicaid?

YesNo
Please select which services you are interested in, you may select more than one.*

Individual TherapyCouples Therapy-NOT AVAILABLEMedication ManagementLife Coaching
Release it Counseling is a predominate hybrid office, that offers both virtual and face to face sessions. Although we offer face to face sessions, we cannot guarantee that you will be able to have face to face sessions. There may be times where you will have to have virtual sessions. Are you receptive to having tele-health (virtual) sessions?*
Are you receptive and agree to seek services with our specialty of Christian Counseling? As we are a Christian Counseling agency.*

YesNo
Please select Your preferred therapist. Whitney is not accepting new clients.*

First Available/No PreferenceCameo Faulkner, MSW, LMSW- VIRTUAL ONLYElektra Smith, MSWYonette Cuneo, MSW, LMSWDr. Church, PMHNP-BC- Medication Management Only
Please list times you are available for sessions; ex: "Tuesdays beginning at 3pm" Please read the proceeding therapists availability; This is the availability of Cameo; Monday-Friday-10a-5p (VIRTUALLY ONLY). Elektra; Tuesday-Friday 10a-4p (In Person Tuesday & Wednesday and Virtual Thrs & Frid).
Please select how you found our agency
Please include any questions comments or concerns you'd like to discuss prior to scheduling.
Client Signature*

Clear
Should be Empty:

Release it Counseling Intake Form

Psychiatric History:

Past Psychiatric Medications

Personal History

Insurance Information