CLIENT’S LEGAL NAME
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First Name
Last Name
BEST CONTACT EMAIL
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BEST CONTACT PHONE
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(###)
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CLIENT’S DATE OF BIRTH
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MM
DD
YYYY
WHAT SERVICES ARE YOU LOOKING FOR?
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INDIVIDUAL THERAPY, COUPLES THERAPY, ADOLESCENT THERAPY, EMDR THERAPY, KAP THERAPY, MEDICATION MANAGEMENT
OTHER CLIENT’S LEGAL NAME, DATE OF BIRTH, PHONE NUMBER AND EMAIL ADDRESS
COUPLES THERAPY ONLY
CLIENT’S HOME STATE
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PROVIDERS CAN ONLY SEE CLIENTS WHO ARE IN STATES THEY ARE LICENSED IN DURING SESSION. PLEASE LET OUR OFFICE KNOW IF YOU WILL NOT BE IN YOUR HOME STATE DURING YOUR SESSIONS.
PAYMENT METHOD
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ARE YOU INTERESTED IN SESSIONS THAT ARE
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WHAT IS BRINGING YOU IN FOR SERVICES AT THIS TIME?
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CHECK ALL THAT APPLY
ARE YOU CURRENTLY TAKING ANY MEDICATIONS FOR PHYSICAL OR MENTAL HEALTH ISSUES? IF YES, PLEASE LIST CURRENT MEDICATIONS, DOSES AND PRESCRIBER.
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HAVE YOU EVER BEEN HOSPITALIZED FOR PSYCHIATRIC REASONS? IS YES, WHEN DID YOUR HOSPITALIZATION OCCUR? HOW LONG WERE YOU HOSPITALIZED? DID YOU SEEK TREATMENT AFTER DISCHARGE?
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ARE THERE ANY PAST OR CURRENT SUBSTANCE USE ISSUES? IF YES, PLEASE DESCRIBE PAST SUBSTANCE USE, PAST TREATMENT, AS WELL AS CURRENT SUBSTANCE USE.
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DO YOU HAVE ANY CURRENT LEGAL ISSUES (CRIMINAL CHARGES, PROBATION/PAROLE, FAMILY COURT ISSUES, CHILD CUSTODY ISSUES, ETC.)? IF YES, PLEASE BRIEFLY DESCRIBE.
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WE HAVE PROVIDERS WHO ARE SPECIFICALLY TRAINED TO PROVIDE SERVICES TO THOSE WHO ARE ACTIVE DUTY MILITARY, VETERANS OR FIRST RESPONDERS. WOULD YOU BE INTERESTED IN SEEING SUCH A PROVIDER?
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WHAT IS YOUR STANDARD APPOINTMENT AVAILABILITY?
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WHAT ARE 2-3 SPECIFIC DAYS AND TIME FRAMES WITHIN THE NEXT 2 WEEKS THAT YOU ARE AVAILABLE FOR AN INTAKE APPOINTMENT?
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PROVIDER PREFERENCE
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HOW DID YOU HEAR ABOUT US?
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