INTAKE FORM Hello and welcome to my therapy practice. Please fill out and click submit at the bottom of the page. PRINTABLE PDF Please enable JavaScript in your browser to complete this form.First Name:Last Name:Referral Source:Date of birth/place:Age:Cell Phone:Messages OK?YesNoOther Phone:Messages OK?YesNoOther phone number is for:WorkHomeEmail:Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOccupation:Employer:Marital Status:How Long?Are you currently in a relationship?How Long?Living situation:Spouse/partner's first nameAge:Occupation:Past significant relationships or marriages (name, when and for how long):Children / Stepchildren / Grandchildren (names and ages, please indicate adoptions):Father (name, age or year/cause of death, occupation, state of residence):Mother (name, age or year/cause of death, occupation, state of residence):Stepparents (name, age or year/cause of death, occupation, state of residence):If your parents divorced, what was your age at the time?Where and with whom did you live from birth to 18: Siblings (name, age or year/cause of death; indicate half & step siblings):Please list 5 words or short phrases to describe your mother: Please list 5 words or short phrases to describe your father: If you lived with stepparents before age 18, briefly describe them as well: Major medical problems, surgeries, accidents, illnesses, etc.: Current & past psychiatric medications, and approximate dates used: Current & past use of alcohol and recreational drugs (please list what you use, how much and how often. Include AA, NA or treatment programs): Family history of alcoholism, mental illness or violence (please include suicide, depression, hospitalization for mental illness, abuse, etc.): Have you ever felt suicidal? NoYesIf yes, how persistently or frequently:Have you ever made a suicide attempt? NoYesIf yes, when:Spiritual orientation or practice, if any:Previous therapy (therapists, approximate dates of treatment, individual or couples): Generally what was your experience of therapy? Was there anything that was particularly helpful or not helpful? Submit
