Intake Form

General Information
Name
First Last
Date
Date Format: MM slash DD slash YYYY
Email (Please enter a secure email to recieve a copy of your intake form)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Day)
Phone (Night)
Age
Occupation
Date of Birth
Date Format: MM slash DD slash YYYY
Place of Birth
Height
Weight
Does your weight fluctuate?
- Yes
- No
If yes, by how much?
Do you have a family physician?
- Yes
- No
Name of Family Physician
Physician Phone Numer
By whom were you referred?
Marital Status
- Single
- Living together
- Engaged
- Married
- Separated
- Divorced
- Widowed
- Remarried
How Many Times?
Do you live in
- House
- Room
- Apartment
- Other
Please Specify
With whom do you live? (check all that apply)
- Parents
- Spouse
- Roommates
- Child(ren)
- Friend(s)
- Others
Please Specify:
Describe your occupation
Does your present work satisfy you?
- Yes
- No
Please Explain
What kinds of jobs have you held in the past?
Have you been in therapy before?
- Yes
- No
Have you ever received any professional assistance for your problems?
- Yes
- No
Have you ever been hospitalized for any psychological/psychiatric problems?
- Yes
- No
When and where?
Does any member of your family suffer from an “emotional” or “mental disorder”?
- Yes
- No
Have you ever attempted suicide?
- Yes
- No
Has any relative attempted or committed suicide?
- Yes
- No

General Information