New Client Intake ( 2 of 3 )

Please complete and electronically sign the below form prior to your first appointment.

First Name

Last Name

Birthday

Address

Phone

Okay to leave a voicemail?

Yes

Okay to send reports via email?

Yes

Age

Which is your dominant hand?

Left

Right

Ambidextrous

Gender:

Gender Identity / Preferred Pronouns:

Employer / Occupation:

Please describe any head/brain injuries or concussions:

Do you have a history or are currently experience seizures?

Yes

If yes, please describe:

Please list your current prescribed medications:

Please list current supplements:

Emergency Contact Name (First/Last):

Emergency Contact Phone Number:

Emergency Contact Address:

Emergency Contact Email:

Birthplace

Where did you grow up?

Do you have any pending legal charges and/or are you on probation? If yes, please explain:

Yes

If yes, please describe:

Does your family have a history of psychiatric issues/disorders?

Yes

If yes, please describe:

Father's Emotional Health:

Good

Fair

Poor

Unknown

Father's Physical Health:

Good

Fair

Poor

Unknown

Describe your Father-child relationship:

Mother's Emotional Health:

Good

Fair

Poor

Unknown

Mother's Physical Health:

Good

Fair

Poor

Unknown

Describe your Mother-child relationship:

Were there any complications during your mother's pregnancy or delivery? If yes, please describe:

Did you live with both parents growing up?

Yes

Are you adopted?

Yes

Was your childhood:

Happy

Unhappy

Mixed

Describe childhood:

Were your adolescent years:

Happy

Unhappy

Mixed

Describe your adolescent years:

Were you ever abused as a child or adolescent?

Yes

If yes, check all that apply:

Physically

Emotionally

Verbally

Sexually

Relationship Status (if married, how long?):

Emotional Health of Current/Most Recent Partner:

Good

Fair

Poor

N/A

Physical Health of Current/Most Recent Partner:

Good

Fair

Poor

N/A

Are you currently/have you ever served in the military?

Yes

Please describe (including Branch and Rank):

Did you ever serve in combat?

Yes

If yes, please describe:

Are you currently under the care of a mental health provider?

Yes

If yes, please provide their contact information below (Name/Phone Number):

Are currently you on Medicaid?

Yes

Please list any allergies:

Are you sensitive to medications (take less than average dose)?

Yes

Number of pregnancies:

Number of Births:

Number of living children:

How often do you get headaches, if any?

Describe any surgeries/accidents:

Describe any chronic (ongoing) issues:

Do you ever hear auditory voices?

Yes

Have you ever had an eating disorder?

Yes

If yes, please specify:

Is there any family history of substance abuse?

Yes

If yes, please specify:

Have you ever used alcohol or drugs to change or alter your behavior/mood?

Yes

If yes, please specify:

Do you experience any symptoms of addiction?

Yes

If yes, please specify:

Have you been hospitalized due to substance use or had any detox treatment?

Yes

If yes, please specify:

How often do you drink alcohol?

What kind of alcohol do you usually drink?

What is your response to alcohol? (No affect/sleep/happy/sad) :

Does alcohol affect your sleep?

Yes

Have you ever been charged with a DUI/DWI?

Yes

If yes, please specify:

Do you find it difficult to separate drug and/or alcohol use from your activities?

Yes

Do you currently smoke cigarettes/vape?

Yes

If yes, have you tried to quit / how long since you've quit?

Do you have sugar cravings?

Yes

What is your response to sugar? (No affect/hyperactivity)

How much sugar do you consume daily?

Do you have caffeine cravings?

Yes

What is your response to caffeine? (No affect/jitters)

How much caffeine do you consume daily?

Are you a light or sound sleeper?

Light

Sound

Are you a restless sleeper or mostly still (wake up in same place)?

Restless

Mostly Still

Do you sleep through the night?

Yes

Describe your morning routine (quiet/undisturbed beginning or TV/Radio/ Noise Welcome):

Have you ever been hospitalized for mental health issues?

Yes

If yes, when was the onset of your symptoms?

Have you ever wished you were dead or wished you could go to sleep and not wake up?

Yes

Have you ever had any thoughts of suicide?

Yes

Have you ever started to work out or worked out the details of acting on these thoughts?

Yes

Have you ever had any intention of acting on thoughts of suicide?

Yes

Have you done anything or started to do anything to end your life?

Yes

Do you currently have suicide ideation?

Yes

Do you fidget/feel the need to move (shake foot, tap finger, etc.)?

Yes

Do you enjoy risk-taking behavior?

Yes

Do you have frustration tolerance?

Yes

Are you able to control anger?

Yes

Do you experience tantrums or engage in violent behavior?

Yes

If yes, how often?

Do you share your worry with others?

Yes

Most common stressors:

Most common response to stress (walk, shut down, withdraw, get busy):

Check all that apply:

Can you catch a ball thrown to you?

Yes

Can you ride a bike?

Yes

Are you able to tell when someone is standing too close to you or you to them?

Yes

Are you a picky eater?

Yes

Are you able to mix foods?

Yes

Do some smells bother you?

Yes

Do you find yourself either hot or cold when no one else is?

Yes

Do you have difficulty understanding if other noises are going on?

Yes

Are light touches uncomfortable?

Yes

Do tags/seams on clothing bother you?

Yes

Are there textures you do not like/cannot tolerate?

Yes

If yes, please specify:

What big transitions and/or change have you experienced at home?

What big transitions and/or change have you experienced at school/work?

Are you organized at school/work and at home?

Yes

Are you insensitive or unaware of others?

Yes

Do you have body awareness? (Awareness of where your body is in space)

Yes

Do you have awareness of feelings of hunger/satiation?

Yes

Do you get food cravings often?

Yes

Do you have awareness of pain/discomfort?

Yes

Are you sensitive to sounds?

Yes

Are you sensitive to lighting or other visual experiences?

Yes

Do you have difficulty with spatial awareness? (Bump into things)

Yes

Are you able to do puzzles/manipulate small pieces easily?

Yes

Do you enjoy a lot of body movements?

Yes

Do you experience visual disturbances?

Yes

Do you have trouble reading?

Yes

Do you have trouble with balance?

Yes

Do you have issues with visual processing?

Yes

Do you have difficulties with speech? (Expressive or receptive)

Yes

Do you often experience vertigo or dizziness?

Yes

Do you have difficulty hearing/ringing/multiple ear infections?

Yes

Do you have difficulty with sense of direction/navigation?

Yes

Do you have memory issues? (Auditory, visual, or tactile)

Yes

Do you have difficulty with short- or long-term memory?

Yes

Do you have auditory processing issues?

Yes

Do you have difficulty with facial recognition?

Yes

What situations cause fear?

Do you have phobias? If yes, please specify:

Mood regulation? (stable/predictable)

Yes

Do you know why you are in certain moods?

Yes

Do circumstances support your mood?

Yes

Do you frequently experience depressive symptoms?

Yes

Do you frequently experience symptoms of anxiety?

Yes

Do you experience panic attacks?

Yes

Are you irritable often?

Yes

Do you have obsessive thoughts/behaviors?

Yes

Do you experience racing thoughts?

Yes

Do you engage in oppositional behaviors? (Do others consider you contrary

Yes

Do you engage in impulsive behaviors?

Yes

Do you have difficulty with attention? (span/flexibility)

Yes

Are you easily distracted/difficult to get back on task?

Yes

Does daydreaming interfere with attention/function?

Yes

Strongest school subject:

Weakest school subject:

Teacher concerns (if any):

Have you had difficulties with homework?

Yes

Describe interactions with peers/siblings (for kids):

Describe Interactions with adults (for kids):

List your interests and hobbies:

Do you exercise regularly?

Yes

If yes, what type and how often?

Are spiritual issues and/or resources important to you in therapy?

Yes

Do you think your immediate/nuclear family (and friends) will be supportive of the changes you would like to make?

Yes

If no, please explain:

Is there anything esle you'd like to share:

Thanks for submitting > Complete Financial Responsibility Form (Form 3 of 3)