Intake Form
Intake Information - Please fill out and press Submit

Please provide the following information for our records. This data is held as privileged and strictly  confidential information, as is all information in our practice. Leave blank any question you would rather not answer.  Fill it in online and then click the SUBMIT button and it will be transmitted to our office. 

If you are making an office visit, or wish to mail us the completed form, you may print out the form which you can download HERE, and fill it in at your leisure, allowing you to bring it into the office in person, or just drop it in the mail.

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Today's Date:
NAME (last, first, MI): *
Name of Parent/Guardian (if client is a minor):
Date of Birth: *
Marital Status:
List children & their ages:
Local Address: *
Home Phone *
May we leave a message?:
Cell Phone:
May we leave a message?:
E-mail: *
May we leave an E-mail message?:
Referred by:: *
Are you currently receiving psychiatric servces, professional counseling or psychotherapy elsewhere?:
Current service provider's name:
Are you currently taking prescribed psychiatric medication (antidepressants or others)?:
If yes, please list:
If no, have you been previously prescribed psychiatric medication?:
If yes, please list:

EMPLOYMENT INFORMATION                                    
Are you currently employed?:
If yes, who is your current employer and position?:
If yes, are you happy at your current position?:
Please list any work-related stressors, if any:

Do you consider yourself to be religious?:
If YES, what is your faith?:
If NO, do you consider yourself to be spiritual?:

Has anyone in your family (either immediate members or relatives) experienced difficulties with the following areas? Select  all that apply.
  Bipolar Disorder
  Anxiety Disorders
  Panic Attacks
  Alcohol / Substance Abuse
  Eating Disorders
  Learning Disabilities
  Suicide Attempts
  Trauma History

How is your physical health at the present moment?:
Please list any persistent physical symptoms or health concerns (such as chronic pain, headaches, diabetes, high blood pressure, cancer, heart condition, etc.): *
Are you having trouble with your sleep habits?:

  If yes, check all that apply from the choices below
  Sleeping too little
  Sleeping too much
  Poor quality sleep
  Disturbing dreams
  Other sleep problems
Specify what "other" sleep problems:
How many times do you exercise each week?:
About how many minutes each time?:
Are you having any difficulties with appetite or eating habits?:

If YES, check all the boxes that apply to your  situation
  Eating less
  Eating More
  Binge eating
  Making yourself throw up
Have you experienced significant weight change in the last 2 months?:
Do you regularly use alcohol?:
In a typical month, how often do you have 4 or more drinks in a 24-hour period?:
How often do you use recreational drugs?:
Have you had suicidal thoughts recently?:
Have you had such thoughts in the past?:
Are you currently in a romantic relationship?:
If yes, how long have you been in this relationship?:
On a scale of 1 to 10, with 10 being the best, how would you rate this relationship?:
In the last year, have you experienced any significant life changes or stressors? If YES, what were they?: *

Have you ever experienced any of the following?  Click all that apply.
  Extreme depressed mood
  Rapid speech
  Mood swings
  Extreme anxiety
  Phobias (extreme fears of something)
  Panic attacks
  Sleep disturbances
  Unexplained losses of time
  Alcohol / Substance Abuse
  Eating disorders
  Frequent body (physical) complaints
  Body image problems
  Repetitive thoughts
  Repetitive behavior (frequent checking, hand washing)
  Homicidal thoughts
  Suicide attempts

                                            OTHER INFORMATION
What do you consider to be your strengths?:
What do you like most about yourself?:
What are effective coping strategies that you have learned?:
What are your goals for therapy?:
If you have any other information about your situation that you would like to submit, please enter it here:

If you have completed the survey, please click SUBMIT.  If you have not completed the required areas (red asterisk), you will be asked to do so before the survey is submitted.  Thank you.
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