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 *
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 *