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Intake Form - Adult
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
Name
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First
Last
Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Birthdate
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Current Age
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Gender
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Male
Female
Relationship Status
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Never Married
Married
Separated
Divorced
Widowed
Domestic Partnership
Name of Children and Ages
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If no children, write "none".
Emergency Contact (Name and relationship to you)
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*This person will not be contacted without a signed release from you.
Emerg. Contact Phone Number
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Have you previously seen a therapist / counselor
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Yes
No
If yes, please give therapist / counselor name and city located
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What brings you into therapy now?
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Please list current medications and dosages
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Name of Physician
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If none, write in "none". Your physician can not be contacted without a release of information signed by you.
Phys. Phone Number
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Name of Psychiatrist
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If none, write in "none" Your psychiatrist can not be contacted without a release of information signed by you.
Psych. Phone Number
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How would you rate your physical health
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Good
Average
Poor
How would you rate your sleeping habits
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Good
Average
Poor
Frequency of recreational drug use?
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Never
Daily
Weekly
Very Infrequently
Briefly describe if health is poor
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Briefly describe problems with sleep
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If using, list drug(s) of choice
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Do you currently experience panic / anxiety?
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No
Yes
Briefly describe your panic / anxiety
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Do you currently experience chronic pain?
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No
Yes
Briefly describe your chronic pain.
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Do you struggle with your level of anger?
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No
Yes
Briefly describe your anger issues.
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Are you currently feeling depression or sad
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No
Yes
Briefly describe your depression / sadness and how long you have been feeling this way.
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Do you have a family history of depression?
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No
Yes
Share what family members have had depression (aunt,father,mother,etc.)
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Do you currently feel suicidal?
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No
Yes
Suicide Crisis Line - 877 727 4747 serving Orange County. If you are feeling suicidal, or someone you know is thinking about suicide, call the 24-hour suicide crisis line to speak with someone who can provide assistance. Or you can phone 911 and let them know you need assistance.
Have you ever been hospitalized for suicidal thoughts?
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No
Yes
Are you currently having relationship problems?
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No
Yes
How long has your relationship been strained?
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Are you currently having employment problems?
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No
Yes
Briefly describe employment issues.
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Are you currently having problems with your children / step-children?
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No
Yes
Briefly describe concerns with your children.
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Please comment below on any areas you answered above that you would like to further clarify. Also, add any additional information that you feel will be helpful to me but I may not have asked about. Thank you!
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Briefly describe your faith or beliefs.
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INSURANCE
My healthcare is covered under the following Insurance Provider
Insurance Provider
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Are you covered by TWO / MULTIPLE insurance companies?
Choose One
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Yes
No
I'm transitioning out of one
List ALL insurance providers in which you have coverage - even if you don't want to use them or transitioning out of one
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Which Insurance Company will you be using?
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Cigna
TriCare
Kaiser
CalOptima / MediCal
Other* List Below
I'd like to discuss my best options for using insurance
I have insurance but am choosing not to use it
*If Other, please list here.
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IMPORTANT: Insurance member number - it's important to list this as your coverage needs to be confirmed.
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How did you hear about my services? Who referred you to me?
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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. During our first session you and I will be able to discuss more in-depth any areas of concern.
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Home
About Me
Talk Therapy
Hypnotherapy
Fees, Insurance, Directions
Why Do You Want Therapy?
Blog
Important Forms
Podcasts
Confidentiality
