intake-form

Why are you seeking help now?

Have you seen a mental health professional before? Have you ever been hospitalized for a psychiatric issue?

Has anyone in your family ever sought help for or experienced mental health or substance use issues?

Do you have any current or prior medical issues?

Are you currently prescribed any medications? Specify all medications and supplements you are presently taking and for what reason:

Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed?

Who is in your family? What is your relationship with them like?

What social activities and relationships do you engage in?

What spiritual practices and cultural influences are important to you?

What was life like as you were growing up, both at home and in school?

What significant education and work/volunteer experiences have you had?

What is your current occupation? What do you do? How long have you been doing it?

Describe your current living situation. Do you live alone, with others, with family, ...?

Do you have any current or prior legal issues?

What strengths and abilities are you bringing to sessions? What needs or preferences do you have that will help us be successful?

What else would you like me to know?

Please list an emergency contact (name, relationship, and phone number)