A Quiet Journey

Quote of the Day

Sometimes the smallest things take up the most room in your heart.

A veces las pequenas cosas ocupan un espacio grande en tu corazon.

~Author Unknown

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(301) 370-6613

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Confidential Intake Form

(Your personal information remains completely confidential and will not be submitted to any outside source or database.)

Today's Date

Referral Source:

Name:

Date of Birth:

Place of Birth:

Age:

Adopted:

Yes No

Address:

City/State:

Zip:

Telephone:

Home: Work: Cell:

May I leave a message on your home phone? Yes No | Cell Phone? Yes No

May I text you appointment reminders and/or non-session related information? Yes No

Email Address:

May I communicate with you through email? Yes No

Emergency Contact:

Name: Relationship: Phone:

Relationship:

Status:

Single Married Divorced

Spouse/Partner:

Age:

Children:

Name	Age

Siblings:

Name	Age

Ethnic Group (Select all that apply)

American Indian/Alaskan Native	Caucasian	Middle Eastern
Asian	Native Hawaiian/Pacific Islander	Hispanic/Latino
Black/African American	Multi-Ethnic/Other

Gender:

Male Female Transexual

Sexual Identity:

Straight Gay Lesbian Bisexual Questioning Transgender

Spiritual Practice

Christian	Judaism	Buddhism	Jehovah's Witness	Gnosticism
Catholic	Islam	Hinduism	7th Day Adventist	Mormonism
Scientology	Metaphysical	None	Other

Do you consider yourself a spiritual person? No Yes

Employment

Current Status:

Full Time Part Time Self-Employed Student

Medical Condition

Any significant medical conditions?

Any current medications and what for?

Medical Doctor/Psychiatrist Phone:

Reason for therapy:

On a scale of one to ten, how motivated are you to resolve this problem?

Any prior experience with therapy and the reason:

For how long and when?

Have you ever experienced extreme mood swings? No Yes

If yes, please describe:

Do you have a history of depression? No Yes

Are you Depressed now? No Yes

Please describe your average amount of sleep per night:

Please describe your eating habits:

Are you having suicidal thoughts? No Yes
If yes, do you have a plan about how you would commit suicide? No Yes

If yes, what is your plan?

Do you have the means to carry out your plan? No Yes

Have you ever made a suicide attempt or been hospitalized for suicidal ideation? No Yes

If yes, please describe the circumstances, how and when:

Is there any drug or alcohol abuse in your history? No Yes

Are you still using? No Yes

If yes, please explain:

How much alcohol do you consume per day? Per week?

Is this contributing to your reasons for entering therapy? No Yes

Are you currently attending any 12 step meetings? No Yes Which ones?

Does anyone in your household use alcohol? No Yes

Do you have any pending legal issues or charges? No Yes Any legal issues at all? No Yes

If yes, please describe:

Do you have any questions or is there anything else you would like me to know?

I have read and accept the Informed Consent terms I have read and accept the HIPPA Notice.

Thank you for taking the time to provide the above information.