Intake - Adult - Liz Birch

Intake Form - Adult
Please complete this form prior to our first session. All information is protected by confidentiality.
** This form is not "secure". Keep that in mind when completing it and prior to sending it to me. I cannot guarantee the security of the internet. This form is just as secure as sending any email over the internet. You can choose to either complete it in its entirety, complete a portion of it and "submit" it to me or we can complete it together in session. Any information you send me in advance will be helpful.

* 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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