Intake Form for Therapeutic Coaching with Amber St. Germain and Play Therapy-DeepPlaySite

Intake Form for Therapeutic Coaching with Amber St. Germain and Play Therapy

Your completion of this form is deeply appreciated as it serves as a guide in commencing our therapeutic journey together. Thank you, Amber St. Germain

First and last name

Have you ever been diagnosed with a personality disorder or any other DSM Disorder, such as Bipolar 1, Schizophrenia, or Schizoaffective Disorder? If yes, please specify below, or scroll down to let me know you’d rather talk with me.

I prefer to share my personal history (eg: ADHD, bipolar, borderline) during our initial phone call or in our initial three sessions.

What medications are you currently taking, if any, and what are they for? Please specify below.

I prefer to share information regarding medications with you during our initial phone call or in our initial three sessions.

Do you have more than a couple of alcoholic drinks most evenings or use any nonprescription drugs that interfere with your relationships or professional life? Please specify below.

I prefer to share information with you regarding substance use during our initial phone call or in our initial three sessions.

What brings you to therapy? What are your most pressing problems currently?

I prefer to discuss what brings me to therapy during our initial phone call or in our initial three sessions.