Intake Form

Below is an online intake form. To provide some level of security over your personal information it will only be linked to your initials and your intake appointment time. You will be asked to fill out hard copies with identifying information at your intake session as well as sign a printout of your answers. This form is only for clients who already have an intake appointment scheduled. Please, have this form filled out and submitted a full 48hrs before your scheduled intake session unless otherwise discussed with me. If you feel uncomfortable submitting online, just let me know and I'll send you a PDF version to print/fill out and bring to session or have a hard copy waiting for you at your appointment. I recommend that you arrive at least 15-20 minutes early if you plan to fill out these forms in office.

Take a deep breath, there are a lot of questions. Know that these are to help me get a better understanding of your needs as we start treatment. I'm so glad that you're taking this step to take good care of yourself and look forward to seeing how I can help!

Identity

Initials (First & Last)

Confirmed Intake Appointment Time

Ethnicity

Religious Preference

Sex Assigned at Birth

Ex. Intersex, Male, Female, Etc

Gender Identity

Pronouns

Sexual/Romantic Orientation

Orientation

Do you need any support and/or are you having any challenges in these areas?

General Health Questionnaire

Initials (First & Last)

Insurance Carrier

Primary Physician

Primary Psychiatrist

List any medications/dosage:

Last Physical:

Any serious health issues?

Please, describe:

My general health is...

My general diet is...

Any special dietary restrictions?

Eating history/challenges?

Do you exercise?

How many hours a week do you exercise?

What activities?

Feelings about your body?

Are your feelings about your body gender related?

Any other information you'd like to share?

Do you smoke cigarettes?

How many/how often?

Any challenges with cigarettes previous/current?

Do you drink alcohol?

How many drinks/how often?

Any challenges with alcohol previous/current?

Do you use cannabis?

How do you consume it?

Any challenges with use previous/current?

Do you use any other substances?

Please, list type, quantity, and whether you have any current or previous challenges.

Do you need any support and/or are you having any challenges in these areas?

Relationships & Sexual Health Questionnaire

Initials (First & Last)

Relationship Identity

Partner 1

Please, list how you refer to one another (ex. girl/boy friend, spouse, partner, lover, etc), how long you've been together, if you live with one another, how you feel the relationship is going (ex. good, neutral, negative, abusive, etc), and anything else you feel is important to share.

Partner 2

Partner 3

Partner 4

Anything else you feel is important to share about your relationships or your relationship history?

Are you sexually active?

Do you use contraception and/or protection?

What type of contraception/protection do you use?

Are you communicating with all partners about sexual health and safety?

Are you a kinky identified individual and/or part of the BDSM community?

If yes, unsure, or curious, please describe:

Do you need any support and/or are you having any challenges in these areas?

How is your social network outside of your romantic relationships?

Are you aware of and/or are you concerned about having any sexually transmitted infections?

Parental Figure 1

Please list their name, age (please note if deceased and when), relationship to you (ex. good, estranged, neutral, etc), and if they suffer from any medical or psychological challenges.

Parental Figure 2

Other Parental Figures:

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Other Significant Family Members:

Anything else important you'd like to share about your family?

Mental Health Questionnaire

Initials (First & Last)

How satisfied are you with your primary relationship?

Please, rate on a scale of 1-10 (with 10 being the most satisfied), and note any needs, challenges, important information, etc.

How satisfied are you with your family relationships?

How satisfied are you with work?

How satisfied are you with school/work?

How satisfied are you with your living environment?

How satisfied are you with your mental health (general)?

How satisfied are you with your sleep schedule?

How satisfied are you with your mood?

How satisfied are you with your anxiety?

Does anyone make you feel unsafe?

If yes, who/why?

Any events you keep re-experiencing?

If yes, what/how often?

Any thoughts about hurting yourself?

If yes, what/how often?

Have you ever hurt yourself?

If yes, what/how often?

Are you having any thoughts about suicide?

If yes, what/how often?

Have you ever attempted suicide?

What/When?

Have you ever been hospitalized for mental health issues?

If yes, when/describe:

Anything else you'd like to share?

Have you been to therapy before?

Please, list the reason, how long you were attending sessions, and what the outcome was for you?

What is your current reason for seeking therapy?

Anything else you'd like to share?

How did you find me?

Name of referral/description of other if relevant:

Thank you for filling out these forms! Please, make sure that you have completed all four of the questionnaires: Identity, General Health, Relationships & Sexual Health, and Mental Health. Below are forms for your reference. Please, review them as you will be asked to acknowledge that you received and accept them when you arrive at session.

Privacy Practices

Acknowledgement of Privacy Practices

Rights and Responsibilities

Office Policies

Hotlines