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New Client Intake ( 2 of 3 )

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

Okay to leave a voicemail?
Okay to send reports via email?
Which is your dominant hand?
Do you have a history or are currently experience seizures?
Do you have any pending legal charges and/or are you on probation? If yes, please explain:
Does your family have a history of psychiatric issues/disorders?
Father's Emotional Health:
Father's Physical Health:
Mother's Emotional Health:
Mother's Physical Health:
Did you live with both parents growing up?
Are you adopted?
Was your childhood:
Were your adolescent years:
Were you ever abused as a child or adolescent?
If yes, check all that apply:
Emotional Health of Current/Most Recent Partner:
Physical Health of Current/Most Recent Partner:
Check all that apply to your current/most recent relationship:
Are you currently/have you ever served in the military?
Did you ever serve in combat?
Are you currently under the care of a mental health provider?
Are currently you on Medicaid?
Are you sensitive to medications (take less than average dose)?
Check all that apply:
Do you ever hear auditory voices?
Have you ever had an eating disorder?
Is there any family history of substance abuse?
Have you ever used alcohol or drugs to change or alter your behavior/mood?
Do you experience any symptoms of addiction?
Have you been hospitalized due to substance use or had any detox treatment?
Does alcohol affect your sleep?
Have you ever been charged with a DUI/DWI?
Do you find it difficult to separate drug and/or alcohol use from your activities?
Do you currently smoke cigarettes/vape?
Do you have sugar cravings?
Do you have caffeine cravings?
Have you ever felt extremely attracted to:
Are you a light or sound sleeper?
Are you a restless sleeper or mostly still (wake up in same place)?
Do you sleep through the night?
Check all that apply:
Have you ever been hospitalized for mental health issues?
Have you ever wished you were dead or wished you could go to sleep and not wake up?
Have you ever had any thoughts of suicide?
Have you ever started to work out or worked out the details of acting on these thoughts?
Have you ever had any intention of acting on thoughts of suicide?
Have you done anything or started to do anything to end your life?
Do you currently have suicide ideation?
Do you fidget/feel the need to move (shake foot, tap finger, etc.)?
Do you enjoy risk-taking behavior?
Do you have frustration tolerance?
Are you able to control anger?
Do you experience tantrums or engage in violent behavior?
Do you share your worry with others?
Check all that apply:
Can you catch a ball thrown to you?
Can you ride a bike?
Are you able to tell when someone is standing too close to you or you to them?
Are you a picky eater?
Are you able to mix foods?
Do some smells bother you?
Do you find yourself either hot or cold when no one else is?
Do you have difficulty understanding if other noises are going on?
Are light touches uncomfortable?
Do tags/seams on clothing bother you?
Are there textures you do not like/cannot tolerate?
Are you organized at school/work and at home?
Are you insensitive or unaware of others?
Do you have body awareness? (Awareness of where your body is in space)
Do you have awareness of feelings of hunger/satiation?
Do you get food cravings often?
Do you have awareness of pain/discomfort?
Are you sensitive to sounds?
Are you sensitive to lighting or other visual experiences?
Do you have difficulty with spatial awareness? (Bump into things)
Are you able to do puzzles/manipulate small pieces easily?
Do you enjoy a lot of body movements?
Do you experience visual disturbances?
Do you have trouble reading?
Do you have trouble with balance?
Do you have issues with visual processing?
Do you have difficulties with speech? (Expressive or receptive)
Do you often experience vertigo or dizziness?
Do you have difficulty hearing/ringing/multiple ear infections?
Do you have difficulty with sense of direction/navigation?
Do you have memory issues? (Auditory, visual, or tactile)
Do you have difficulty with short- or long-term memory?
Do you have auditory processing issues?
Do you have difficulty with facial recognition?
Mood regulation? (stable/predictable)
Do you know why you are in certain moods?
Do circumstances support your mood?
Do you frequently experience depressive symptoms?
Do you frequently experience symptoms of anxiety?
Do you experience panic attacks?
Are you irritable often?
Do you have obsessive thoughts/behaviors?
Do you experience racing thoughts?
Do you engage in oppositional behaviors? (Do others consider you contrary
Do you engage in impulsive behaviors?
Do you have difficulty with attention? (span/flexibility)
Are you easily distracted/difficult to get back on task?
Does daydreaming interfere with attention/function?
Have you had difficulties with homework?
Check all that apply:
Do you exercise regularly?
Are spiritual issues and/or resources important to you in therapy?
Do you think your immediate/nuclear family (and friends) will be supportive of the changes you would like to make?

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

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