Intake Form

Your Information

* Indicates required field

Name *

First

Last

Date of Birth *

Phone Number *

Preferred Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Other Contacts

Spouse/Guardian *

First

Last

Phone Number *

Emergency Contact *

First

Last

Phone Number *

Primary Physician *

First

Last

Phone Number *

Financial Contact

Person Financially Responsible *

First

Last

Address of Person Financially Responsible *

Line 1

Line 2

City

State

Zip Code

Country

Relationship *

Employment Status *

Patient Information

What issues/concerns have resulted in your seeking therapy at this time? *

Goal for psychotherapy? *

Have you ever had the same or similar condition? *

Yes No Other/Don't Know

If yes, when? *

If yes, describe *

What attempts have you previously made to resolve this issue? *

Family history of mental health or substance abuse? *

Yes No Other/It's Complicated

If yes, who? *

If yes, when? *

If yes, describe *

Physical Traits

Diet *

Alcohol Use *

How much per week? *

Other Substance Use *

What is it? *

How much per week? *

How were you referred? *

Submit