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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Confidential Intake Form

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

Name:
City/State: Zip:
Telephone:
May I leave a message on your home phone?  |  Cell Phone?
   May I text you appointment reminders and/or non-session related information?
May I communicate with you through email?
Emergency Contact:
Relationship: 
Status:  
Spouse/Partner:
Children:
Name Age
Siblings:
Name Age
Ethnic Group (Select all that apply)
Gender: Male  Female  Transexual 
Sexual Identity: Straight  Gay  Lesbian  Bisexual  Questioning  Transgender 
Spiritual Practice
Judaism
 
 
 Do you consider yourself a spiritual person?  
Employment
 Current Status:              
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?   Are you Depressed now?  
 Please describe your average amount of sleep per night:
 Please describe your eating habits:
 Are you having suicidal thoughts?   
 If yes, do you have a plan about how you would commit suicide?   
If yes, what is your plan?
Do you have the means to carry out your plan?
Have you ever made a suicide attempt or been hospitalized for suicidal ideation?
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?   
 Are you currently attending any 12 step meetings?          Which ones?
 Does anyone in your household use alcohol?   
 Do you have any pending legal issues or charges? Any legal issues at all?   
 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.