Intake Form

 

Please fill out as much as your comfortable with.  Please have insurance information available at time of vist.

Name
Date of Birth (IMPORTANT)
Address
With whom do you live?
Email Address
Home Phone
Work Phone
Mobile Phone
Who referred you to me?
Insurance Company
Your Name and Insurance ID:
Your Social Security (May be left blank but required upon first visit)
Insured Name (If differs from your own)
Insured ID number
Insured Social Security Number (may be provided at first visit)
Insured Date of Birth
Policy or Group Number
Briefly, what brings you to therapy at this time?
Family and history:
Marital History:
Name of spouse/partner:
Legal status:
Years married/together:
Previous marriages/primary relationships:
Children (Names and Ages):
If a woman, are you pregnant?
Stepchildren (Names and Ages - add names of parents next to each child please):
Religious background (how you were broughtup):
Religion of mother:
Religion of father:
Nationality of mother:
Nationality of father:
Mothers Name:
Mothers Age (if alive, if deceased, your age at time of her death):
Mothers current location:
Fathers Name:
Fathers Age (if alive, if deceased, your age at time of his death):
Fathers current location:
Step-mothers name:
Step-mothers age:
Step-fathers name:
Step-fathers age:
(If adopted) Biological Mothers Name:
(If adopted) Biological Mothers Age:
(If adopted) Biological Mothers current location:
(If adopted) Biological Fathers Name:
(If adopted) Biological Fathers Age:
(If adopted) Biological Fathers current location:
Biological siblings including their names, ages and location:
Your position in the family (for example, oldest):
Describe your mother briefly:
Describe your father briefly:
Other relatives who were especially important to you when you were growing up (for example, a gradparent):
Choose three words which would best describe each of your brothers and sisters, if you have any:
Choose three words your family used or might have used to describe you when you were growing up:
Your reaction to beginning school:
Your experience of school thereafter:
Age at your earliest sexual experience:
Your earliest memories
Most significant person in your life prior to marriage - describe and state why:
Comments
Who took pimary care of you as an infant:
Describe your early care, including any particular stress during your infancy (for example hospitalization of you or an individual who took care of you, losses in your family, divorce and so on):
Currently Employed?
How long?
Employer Name:
Employer Address:
Job Title:
If unemployed, how long?
Primary source of income:
Occupation:
Summary of work history:
Highest grade completed:
Grammar schools attended including location:
High Schools including location:
Colleges attended, including location:
Graduate Schools, including locations
Academic Performance

Emotional Health Assessment (Yes/No Describe all that apply)

Depression
Anxiety
Panic Attacks
Fatigue
Indecisive
Shortness of Breath
Feelings of Detachment
Numbness
Dizziness
Changes / problems with eating habits:
Trouble Concentrating
Memory problems
Uncontrollable thoughts or impulses:
Irrational fears or phobias
Alchohol abuse
History of alcohol abuse
Drug abuse
History of drug abuse
Amount, frequency, age of onset and last used (drug or alcohol)
History of sexual or physical abuse:
Obsessive thoughts or behavior
Sleep problems
Other problems
Previous psychiatric/psychological treatment?
Name of previous psychotherapists or psychiatrists (Please include treatment person and title,starting withmost recent, and approximate dates of treatment as well as general results)
Current Psychiatrist or APRN including address and phone number
Current Psychotropic Medications (Name of drug, dosage, when prescribed, by whome and response)
Previous Psychotropic Medications (Name of drug, dosage, when prescribed, by whome and response)
Primary care physician, address and phone
For women, Gynecologist name and address
Emergancy contact, name and phone:


Medical History

Heart Problems
Diabetes
Liver disease
High blood pressure
Stomach problems
Recent injury or surgery
Thyroid (last time checked)
Other Medical Problems
Additional history of Medical problems:
Current Medications (Name of drug, dosage, when prescribed, by whome and response)
Previous Medications (Name of drug, dosage, when prescribed, by whome and response)


Describe how interaction with others is stressful:

Marital relationship
Work
Children
Sexual
Other
Major present stressors
Greatest sources of satisfaction
Any other comments to help me understand you?
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