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Intake
Form for
Clients
This
is a way to get to know you better and provided necessary information
for the first session. If you want to save time your first session,
please print it out, complete it, and bring it with you to your first
session.
Thank you!
Name(s):
__________________________________
DOB: _____________________
Residential
Address (please no P.O. Boxes):
________________________________________________________________________
Phone
Number(s): _________________________________________________________
Worplace:
_____________________ Occupation:
________________________________
Insurance,
if any:
________________________________________________________________________
How
you heard about me: (like through a search engine, friend, agency,
etc.):
________________________________________________________________________
Medication(s)
for psychiatric care (please include dosage):
________________________________________________________________________
________________________________________________________________________
Prescribing
psychiatrist or MD:
______________________________________________
Past
therapists/psychiatric care:
Name
of therapist/tx ctr Dates of service
(month/yr) Outcome?
_________________________________________________________________________________________________
___________________________________________________________________________________________________
Past
substance abuse and/or
treatment:
Dates of
use Substances used (please note
if you rec’d. treatment or used self-help groups to recover)
_________________________________________________________________________
_________________________________________________________________________
Symptoms that are of concern to you now:
________________________________________________________________________
________________________________________________________________________
Family History of Mental Illness or Substance Abuse:
Have you wanted to or tried to
commit suicide in the past? Have you been hospitalized for psychiatric
reasons?
Do
you have any traumatic events from the past that you have had a hard
time letting go of in the present? If so, please describe briefly and
date/age when it happened. Examples: childhood physical or sexual
abuse; car or industrial accidents; loss of loved one; physical or
sexual assault.
Do
you have any health issues that affect your mood, ability to think,
self image, or other psychological functioning? Examples: Irritable
Bowel Syndrome; Fibromyalgia; HIV; Hepatitis; etc.
Who
do you live with? What are the names and ages of the people who
live with you, and your relationship to them?
Thank
you for taking the time to complete this. It should prove helpful
in my getting to know you.
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