Intake Form

*First Name:

*Last Name:

*Date of Birth:

(MM/DD/YYYY)

*Street Address:

*City:

*State:

*Zip:

*Home Phone:

- -

*Is it ok to identify myself when I call this number?:

Yes

No

*Work/Second Number:

- -	Please enter a second number where you can be reached:

*Is it ok to identify myself when calling this number?:

Yes

No

Email Address:

Please enter an email address if you would like to be contacted by email.

*Briefly describe the problem/s you are having:

(chars left: 5000)

Briefly describe the current problem/symptoms you are experiencing; when they began; have they gotten better or worse? Any treatment so far? Have drugs and alcohol been involved? Are other factors involved (financial, marital, family, school, career, incest, repressed memories, etc)

*Do you take drugs?:

Yes

No

If yes, what kind and how often?:

(chars left: 500)

Please list any drugs that you take, and how often you use them.

*Do you drink Alcohol?:

Yes

No

If yes, how much?:

(chars left: 500)

Please types and amounts, being as accurate as possible.

*Are you taking any medications?:

Yes

No

If yes, what kind and how often?:

(chars left: 1000)

Please list all prescribed and OTC Medications you may be taking and how often you take them:

*Do you have Insurance?:

Yes

No

If yes, name of Insurance Company or Group:

(chars left: 500)

Insurance is not necessary for counseling.

*Have you ever been hospitalized for a Mental Illness, Personality Disorder, etc?:

Yes

No

If yes, please describe:

(chars left: 1000)

Please list date, reason, length of hospital stay, etc.

*Have you had previous counseling?:

Yes

No

If yes, please describe:

(chars left: 1000)

Name and Phone Numbers of Therapists, Number of Sessions, Type of Therapy, etc.