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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: