General Intake

All of this information is considered confidential.

    First Name (required)

    Last Name (required)

    Your Email (required)

    Your Age (required)

    Birthdate (required)

    Street Address (required)

    City (required)

    State

    Zip Code (required)

    Home Phone (required)

    Work Phone (required)

    Cell Phone (required)

    What services are you requesting?
    Professional ConsultationFace to Face Counseling at your officeSubstance Use Evaluatione-Therapy or Online CounselingIntegrated Yoga TherapyRecovery Maintenance SupportHelp with Chronic Pain ManagementTelephone CounselingOther (please explain)

    Describe other:

    How did you hear about my services?

    Briefly describe what you want from or hope to accomplish with these services.

    Do you have specific concerns you want to address?

    How or what have you done to deal with these concerns or this situation? ...what has helped?

    What are your strengths?

    Please describe any previous counseling or therapy services; date & location

    What was helpful & what was not so helpful?

    Are you taking any medications? If so, please list what they are & what you are taking them for & the name/contact information of the prescribing medical provider.

    May I contact them?
    yesno

    When was your last visit to the doctor and what was the purpose of the appointment?

    Who is your doctor?

    May I contact them?
    yesno

    Doctor Address & Phone:

    Is substance use (yours or someone else) a concern or causing problems for you? Please explain.

    If you consume alcohol or other drugs, please list them, how much you are currently using, any periods of controlled use or abstinence.

    Current and most recent 3 years employment history

    Military experience? What & when

    Please describe your current living arrangements; single, married, divorced, living with family or partner, homeless, etc.

    Please describe any physical symptoms you are having (or in past 12 months):
    Quality of sleep & # of hours of sleepAppetite/weight gain or lossHeadachesFatigueTrauma HistoryOther (please explain)

    Explain Other:

    Any Family medical history you think is important to share?

    If you have health insurance and plan to use it to pay for services, please provide the following

    Name of Insurance Company

    ID#

    Name of your coverage plan

    Group #

    Provider Relations Phone #

    Name of Member

    Date of Birth

    Employer

    Please contact your Insurance representative to confirm they have me listed as an in-network provider, your coverage for these services, your co-pay amount, and deductible.

    Do you have any questions?

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