Intake Information
ALL INFORMATION MUST BE FILLED IN COMPLETELY.
First name
Last name
Date of Birth
Sex
Male
Female
Address
Home Phone
Cell Phone
Work Phone
Marital Status
Single
Married
Widowed
Separated
Divorced
When do you work?
Days
Nights
Both Days and Nights
Unemployed
If we may contact you by e-mail, please list here:
Who may we thank for referring you?
Are you a veteran
Yes
No
Emergency Contact Person
Emergency Contact Person Relationship to You
Emergency Contact Person Phone Number
Person Responsible for Account
Address of Person Responsible for Account
Relationship to Person Responsible for Account
Phone Number of Person Responsible for Account
INSURANCE INFORMATION
Please Note: We File Primary Insurance Only
Primary Insurance Company (or enter self-pay)
Primary Insurance Identification Number (Required is using insurance)
Primary Insurance Identification Group Number
Insured Employee Full Name (Required is using insurance)
Insured Employee's Date of Birth (Required is using insurance)
Insured Employee's Employer
Insured Employee's Employer Address
Insured Employee's Relationship to You
PSYCH-SOCIAL INFORMATION
Reason for Visit
Current Stressors/Problems
Past Therapy/Psychiatric Treatment?
Yes
No
If "Yes", how many times?
If "Yes", share dates, places and therapist name (Do your best)
Number of marriages (including current marriage)
If married once or more, indicate length of each marriage (years)
Number of children
If you have children, what are their ages
Number of persons in household
Names, Relation and Ages of Persons in Household
Last grade completed/Level of education
Current job and how long at the job?
Number of jobs held in the past five (5) years
Do you have any current or past legal proceedings?
Yes
No
If yes, please explain
MEDICAL INFORMATION
Some symptoms which may seem to be psychological in nature have a physical cause. It is important to obtain medical history, recent symptoms, past major illnesses and surgeries, current medications, lifestyle health habits, and family history of medical and psychological problems. This information will be kept confidential.
Do You Have a Primary Care Physician Name
Yes
No
Primary Care Physician Name
Date of Last Visit (Approximate)
Primary Care Physician Phone Number
Primary Care Physician Address
Please check any of the following symptoms experienced within the last three (3) months
Allergies
Abdominal pain/cramps
Back pain
Blackouts/amnesia
Blood pressure problem
Blurred vision
Change in sex drive
Change in speech (slurred/stuttering)
Chest pain or discomfort
Concentration problems
Constipation
Diarrhea
Difficulty breathing
Difficulty sleeping
Difficulty swallowing
Dizziness/light-headedness
Fainting
Frequent cough
Headaches
Impotence
Increased need for sleep
Irritability
Memory problems
Nausea or vomiting
Night sweats
Tremors
Palpitations/pounding heartbeat
Racing heart rate
Restlessness
Ringing or roaring in ear
Weight gain with(out) increase in appetite
Weight loss with decrease in appetite
Weight loss without decrease in appetite
None of the above
Please list any symptoms experienced within the last three (3) months that were not on the list.
Please list any significant illnesses, injuries, or surgeries and dates
Please list all medications taken in the last six (6) months (including over-the-counter medications)
Do you use tobacco?
Yes
No
If "Yes", how much per day/week/month
Do you smoke marijuana?
Yes
No
If "Yes", how much per day/week/month
Do you drink alcohol (beer, wine, liquor)?
Yes
No
If "Yes", how much per day/week/month
Do you drink caffeinated drinks (coffee, soft drinks, tea)?
Yes
No
If "Yes", how much per day/week/month
Please check any of these you have suffered from
Alcohol or drug problems
Depression
Anxiety or “nerve” problems
Schizophrenia
Attention Deficit Disorder
None of these
Please check any of these your parents or grand parents have suffered from
Alcohol or drug problems
Depression
Anxiety or “nerve” problems
Schizophrenia
Attention Deficit Disorder
None of these
Unknown
FAITH, RELIGIOUS AND SPIRITUAL QUESTIONS
On a scale of "None" to "Great Deal" how much is faith, spirituality, religion and/or God a source of strength and comfort to you?
None
1
2
3
4
5
Great Deal
Do you pray?
Yes
No
How often do you pray?
Never
Monthly
Weekly
Daily
Does your faith play an important role in your life?
Yes
No
N/A
Do you attend regular worship services?
Never
Monthly
Weekly
More Than Once a Week
Does you religious faith or spirituality influence how you take care of yourself and your health?
Yes
No
N/A
What faith, religion or spirituality do you practice? (Type "none" if none is applicable)
Your Signature
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