Intake - Adult - Liz Birch

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 *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Birthdate *

Current Age *

Gender *

Relationship Status *

Name of Children and Ages *

Emergency Contact (Name and relationship to you) *

Emerg. Contact Phone Number *

Have you previously seen a therapist / counselor *

If yes, please give therapist / counselor name and city located *

What brings you into therapy now? *

Please list current medications and dosages *

Name of Physician *

Phys. Phone Number *

Name of Psychiatrist *

Psych. Phone Number *

How would you rate your physical health *

How would you rate your sleeping habits *

Frequency of recreational drug use? *

Briefly describe if health is poor *

Briefly describe problems with sleep *

If using, list drug(s) of choice *

Do you currently experience panic / anxiety? *

Briefly describe your panic / anxiety *

Do you currently experience chronic pain? *

Briefly describe your chronic pain. *

Do you struggle with your level of anger? *

Briefly describe your anger issues. *

Are you currently feeling depression or sad *

Briefly describe your depression / sadness and how long you have been feeling this way. *

Do you have a family history of depression? *

Share what family members have had depression (aunt,father,mother,etc.) *

Do you currently feel suicidal? *

Have you ever been hospitalized for suicidal thoughts? *

Are you currently having relationship problems? *

How long has your relationship been strained? *

Are you currently having employment problems? *

Briefly describe employment issues. *

Are you currently having problems with your children / step-children? *

Briefly describe concerns with your children. *

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! *

Briefly describe your faith or beliefs. *

How did you hear about my services? Who referred you to me? *

*If Other, please list which insurance company you have *

Insurance member number - it's important to list this as your coverage needs to be confirmed. *

Thank you for taking the time to complete this form either in part or in its entirety. During our first session you and I will be able to discuss more in-depth any areas of concern.

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Intake Form - AdultPlease 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.

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.