Intake - Military - Anxiety & Depression Therapy - Orange County CA

Intake Form - Military

Please complete this form prior to our first session. All information is protected by confidentiality.
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Today's Date *

Name *

First

Last

Phone Number *

Can I leave a message at this number? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of Spouse / Partner *

First

Last

Spouse in the military? *

Email *

Birthdate *

Gender *

Current Age *

Relationship Status *

Age of Spouse *

# of Years Married *

Name of children and ages *

Name of Emergency Contact *

First

Last

What is your relationship with Emergency Contact? (Wife, Aunt, Uncle, Friend,etc.) *

Phone # of Emergency Contact *

What brings you to therapy now? *

Have you previously seen a counselor / therapist? *

Approx dates of previous therapy *

Name of therapist and city located *

Military

Branch of Service *

Unit *

MOS *

Dates of Service - Entry date *

Discharge date *

Please list your type of discharge *

Veteran of *

Other *

Have a copy of your DD214? *

Have you served in a combat theater? *

Where *

Dates *

Do you currently have weapons in your home? *

Wounds / Injuries *

Service related disability - state % *

Describe injuries *

Service related disability for? *

Other - financial assistance *

Education

Name of High School *

Name of College / Tech School *

City and State *

Year Graduated *

Years attended or Graduated *

Employment

Current Employer *

If not employed are you able to work? *

City and State *

Dates of Employment *

Medical

Current Medication *

Dosage *

Reason for taking *

Primary Physician *

Psychiatrist *

Other Physician *

City and State *

Phone Number *

Have you received a Dx of PTSD? *

When were you first diagnosed? (month/year) *

Have you received a Dx of TBI? *

When were you first diagnosed? (month/year) *

Do you use recreational substances? *

What are your substance(s) of choice? *

Do you have more than 5 alcoholic drinks / week? *

Have you addressed the alcohol/substance use with your physician? *

Symptoms / Behaviors

Legal

Have you been arrested since discharge? *

If arrest, dates of incident *

Do you need low cost / free legal counsel? *

If yes, state charges *

Do you currently have any pending charges? *

Using TriCare insurance *

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

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