Home
About Me
Talk Therapy
Hypnotherapy
Fees, Insurance, Directions
Why Do You Want Therapy?
Blog
Important Forms
Podcasts
Confidentiality
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
*
Male
Female
Relationship Status
*
Never Married
Married
Separated
Divorced
Widowed
Domestic Partnership
Name of Children and Ages
*
If no children, write "none".
Emergency Contact (Name and relationship to you)
*
*This person will not be contacted without a signed release from you.
Emerg. Contact Phone Number
*
Have you previously seen a therapist / counselor
*
Yes
No
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
*
If none, write in "none". Your physician can not be contacted without a release of information signed by you.
Phys. Phone Number
*
Name of Psychiatrist
*
If none, write in "none" Your psychiatrist can not be contacted without a release of information signed by you.
Psych. Phone Number
*
How would you rate your physical health
*
Good
Average
Poor
How would you rate your sleeping habits
*
Good
Average
Poor
Frequency of recreational drug use?
*
Never
Daily
Weekly
Very Infrequently
Briefly describe if health is poor
*
Briefly describe problems with sleep
*
If using, list drug(s) of choice
*
Do you currently experience panic / anxiety?
*
No
Yes
Briefly describe your panic / anxiety
*
Do you currently experience chronic pain?
*
No
Yes
Briefly describe your chronic pain.
*
Do you struggle with your level of anger?
*
No
Yes
Briefly describe your anger issues.
*
Are you currently feeling depression or sad
*
No
Yes
Briefly describe your depression / sadness and how long you have been feeling this way.
*
Do you have a family history of depression?
*
No
Yes
Share what family members have had depression (aunt,father,mother,etc.)
*
Do you currently feel suicidal?
*
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?
*
No
Yes
Are you currently having relationship problems?
*
No
Yes
How long has your relationship been strained?
*
Are you currently having employment problems?
*
No
Yes
Briefly describe employment issues.
*
Are you currently having problems with your children / step-children?
*
No
Yes
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?
*
Which Insurance Company will you be using?
*
CalOptima
Cigna
TriCare
Other*
Not Using Insurance
*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.
Submit
Home
About Me
Talk Therapy
Hypnotherapy
Fees, Insurance, Directions
Why Do You Want Therapy?
Blog
Important Forms
Podcasts
Confidentiality