Client Intake Form

Welcome! Please complete this intake form so we can better understand your needs and provide you with the best possible service. All information will be kept confidential. Fields marked with * are required.

Date of Submission *

Full Legal Name *

Preferred Name (if different)

Date of Birth *

Age *

Preferred Pronouns

Current Address *

City *

State/Province *

ZIP/Postal Code *

Primary Phone Number *

Alternate Phone Number

Email Address *

Preferred Method of Contact *

Phone

Email

Text Message

No Preference

Best Time to Contact You

Morning (8am-12pm)

Afternoon (12pm-5pm)

Evening (5pm-8pm)

Anytime

May we leave a voicemail?

Yes

No

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Occupation

Employer

If referred by someone, please provide their name

What brings you here today? Please describe your primary concern or reason for seeking services *

Have you received services for this concern before?

Yes

No

If yes, please describe previous treatment or services received

What are your goals for our work together?

Do you have health insurance?

Yes

No

Prefer not to say

Insurance Company Name

Policy Number

Group Number

Primary Care Physician Name

Primary Care Physician Phone

Are you currently taking any medications?

Yes

No

Prefer not to say

If yes, please list all current medications, dosages, and prescribing doctors

Please list any other medical conditions or health concerns

Please specify allergies and reactions

Have you ever been hospitalized for medical or mental health reasons?

Yes

No

Prefer not to say

If yes, please provide details (when, where, reason)

Have you ever had surgery?

Yes

No

Prefer not to say

If yes, please list surgeries and dates

Please list any significant family medical history (parents, siblings, grandparents)

Is there anything else you would like us to know?

I certify that the information provided above is true and accurate to the best of my knowledge *

Yes, I certify

No

Client Intake Form

Date of Submission *

Full Legal Name *

Preferred Name (if different)

Date of Birth *

Age *

Gender

Preferred Pronouns

Current Address *

City *

State/Province *

ZIP/Postal Code *

Primary Phone Number *

Alternate Phone Number

Email Address *

Preferred Method of Contact *

Best Time to Contact You

May we leave a voicemail?

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Marital Status

Occupation

Employer

Employment Status

How did you hear about us?

If referred by someone, please provide their name

What brings you here today? Please describe your primary concern or reason for seeking services *

How long have you been experiencing this concern?

Have you received services for this concern before?

If yes, please describe previous treatment or services received

What are your goals for our work together?

Do you have health insurance?

Insurance Company Name

Policy Number

Group Number

Primary Care Physician Name

Primary Care Physician Phone

Are you currently taking any medications?

If yes, please list all current medications, dosages, and prescribing doctors

Do you have any of the following medical conditions? (check all that apply)

Please list any other medical conditions or health concerns

Do you have any allergies? (check all that apply)

Please specify allergies and reactions

Have you ever been hospitalized for medical or mental health reasons?

If yes, please provide details (when, where, reason)

Have you ever had surgery?

If yes, please list surgeries and dates

Please list any significant family medical history (parents, siblings, grandparents)

Lifestyle Factors (check all that apply)

On a scale of 1-10, how would you rate your current stress level?

On a scale of 1-10, how would you rate your current overall health?

Is there anything else you would like us to know?

I certify that the information provided above is true and accurate to the best of my knowledge *

Signature (Type your full name) *

Date *