Intake Form

Personal Information

Client's First Name: *

Last Name: *

Date of birth: *

Age: *

SSN (Social Security Number): *

Contact Information:

Address: *

Phone *

Email *

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Emergency Contact: *

Name
Number

Demographic Information:

Marital Status: *

Single

Married

Divorce

Widowed

Other (please specify)………………. *

Ethnicity: *

Caucasian/White

African American/Black

Hispanic/Latino

Asian/Pacific Islander Native American

Other (please specify below)……………………………………………..

Other (please specify here)…………………………………………….. *

Religion: *

Other (please specify your employment)………………………………………………………. *

Referral Information:

- Other (please specify who referred you) *

Medical History: *

Medical Conditions:
Current Medications:

Behavioral Health History:

Please state yes or no if you have experienced the following: *

Trauma
Stress
Depression
Anxiety
Anger/ Irritability
Flashbacks
Hopelessness
Nightmares
Chest Pain
Migraine
Panic Attacks
Others………………………………………………………………..

Current Symptoms/Concerns:

Psychiatric History: *

Previous Diagnoses: *

Previous Treatments: *

Social and Family History:

Living Situation: *

- Alone

- With Family

- With Roommates

- Other (please specify below)

Family Support: *

Education Level: *

Legal History: *

Any legal issues or involvement?

Expectations from us: *

Insurance Information:

Insurance Provider: *

Policy Number: *

Group Number: *

Consent and Authorization: I, the undersigned, hereby consent to participate in the Behavioral Health Program and authorize the release of information to facilitate my treatment.

Client's Signature: *

Clear

Date *

Privacy Notice: All information provided will be kept confidential in accordance with privacy laws and regulations. Exceptions may apply in situations where there is a risk of harm to self or others.