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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
*
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
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First
Last
Spouse in the military?
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No
Yes
Email
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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
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MOS
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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
*
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
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Current Medication
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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
*
Phone Number
*
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)
.
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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
TriCare insurance member #
*
Thank you for taking the time to complete this form. 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