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Intake Form - Military
Please complete this form prior to our first session. All information is protected by confidentiality.
** This is a Secure form. All information sent will be encrypted.
*
Indicates required field
Today's Date
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Name
*
First
Last
Phone Number
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Can I leave a message at this number?
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Yes
No
Address
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Line 1
Line 2
City
State
Zip Code
Country
Name of Spouse / Partner
*
First
Last
Spouse in the military?
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No
Yes
Email
*
Birthdate
*
Gender
*
Male
Female
Current Age
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Relationship Status
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Never Married
Married
Domestic Partnership
Separated
Divorced
Widowed
Age of Spouse
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# of Years Married
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Name of children and ages
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If no children, write "none"
Name of Emergency Contact
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First
Last
What is your relationship with Emergency Contact? (Wife, Aunt, Uncle, Friend,etc.)
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Phone # of Emergency Contact
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What brings you to therapy now?
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Have you previously seen a counselor / therapist?
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Yes
No
Approx dates of previous therapy
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Name of therapist and city located
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Military
Branch of Service
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U.S. Army
U.S. Air Force
U.S. Coast Guard
U.S. Marine Corps
U.S. Navy
Unit
*
MOS
*
Dates of Service - Entry date
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Discharge date
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Please list your type of discharge
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Veteran of
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Vietnam (1962 - 1973)
Somali (1992 - 1995)
Afghanistan - OEF (2001 -present)
Iraq - OIF (2003 - 2011)
Pakistan (2004 - present)
Operation Ocean Shield (2009 - present)
War on ISIL (2014 - present)
Other
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Have a copy of your DD214?
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Yes
No
Please bring a copy of your DD-214 to your first session so it can be retained in your file.
Have you served in a combat theater?
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Yes
No
Where
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Dates
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Do you currently have weapons in your home?
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No
Yes
Wounds / Injuries
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Yes
No
Service related disability - state %
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Describe injuries
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Service related disability for?
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Receiving
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SSI
SSDI
VA Pension
Retirement
Not receiving financial support
Other - financial assistance
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Education
Name of High School
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Name of College / Tech School
*
City and State
*
City and State
*
Year Graduated
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Years attended or Graduated
*
Employment
Current Employer
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If not employed, state "Not Employed"
If not employed are you able to work?
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Yes
No
City and State
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Dates of Employment
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Medical
Current Medication
*
Current Medication
*
Current Medication
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Dosage
*
Dosage
*
Dosage
*
Reason for taking
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Reason for taking
*
Reason for taking
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Primary Physician
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If you currently do not have a personal physician please indicate with "none".
Psychiatrist
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Other Physician
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City and State
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City and State
*
City and State
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Phone Number
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Phone Number
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Phone Number
*
Have you received a Dx of PTSD?
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No
Yes
When were you first diagnosed? (month/year)
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Have you received a Dx of TBI?
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No
Yes
When were you first diagnosed? (month/year)
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Do you use recreational substances?
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No
Yes
What are your substance(s) of choice?
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Do you have more than 5 alcoholic drinks / week?
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No
Yes
Have you addressed the alcohol/substance use with your physician?
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No
Yes
Symptoms / Behaviors
Check all that apply
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Anxiety
Anger
Nightmares
Panic
Other not mentioned above
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.
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Startle Response
Fear
Sadness
Hypersexuality (increase)
.
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Headache
Dizziness
Angry Outbursts
Hyposexuality (lack of interest)
.
*
Can't Concentrate
Poor Memory
Frustration
Self-Harm
Legal
Have you been arrested since discharge?
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No
Yes
If arrest, dates of incident
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Do you need low cost / free legal counsel?
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No
Yes
If yes, state charges
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Do you currently have any pending charges?
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No
Yes
Using TriCare insurance
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Yes
No
I will be using a different insurance, not TriCare
I have insurance but am choosing not to use it
TriCare insurance member #
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Other insurance - Name and Insurance #
*
Notice to clients and prospective clients
:
Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.
You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service, or at any time during treatment.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, or how to dispute a bill, see your Estimate, or visit
www.cms.gov/nosurprises
.
The above statement is now required by law to be posted effective January 1, 2022. This new law protects consumers from "surprise" bills from any health care provider which is great for all of us. In my practice, I do not bill for services. Each session is to be paid in full prior to you receiving the session. Whether you are not using insurance and paying in full for your session, or paying your insurance co-pay, payment is to be received prior to session. This avoids any client holding any type of monetary balance.
Thank you for taking the time to complete this form. You will have an opportunity to discuss/clarify any information on this form. Please complete as much as possible.
When you click Submit a copy will be sent to me. ~ Liz Birch, LMFT
Submit
Home
About Me
Talk Therapy
Hypnotherapy
Fees, Insurance, Directions
Why Do You Want Therapy?
Blog
Important Forms
Podcasts
Confidentiality