Please take a few moments to fill out this intake form before your first appointment. If you are completing this form on a smartphone, you may need to turn the phone on its side to switch to landscape orientation.

  • Yes No

  • (optional)

  • This is the person I would call in the instance of an emergency

  • Single, Partnered, Dating, Married, etc.
  • Yes No
  • Yes No
  • Mildly Moderately Severely
  • Lifestyle (the way you live your life) Activities (things you normally do or would like to do) Relationships (your ability to form or maintain relationships with others) Eating Sleeping Mood
    (Check all that apply)
  • Yes No
  • Yes No
  • Yes No
  • Depression Low Energy Low self-esteem Poor concentration Lack of interest/enjoyment in life Feeling hopeless Feeling worthless Feeling guilty or shameful Sleep changes Loneliness Bad dreams/Nightmares Feeling ignored/abandoned Appetite changes Mood swings Thoughts of hurting self Thoughts of hurting others Isolating from others/social withdrawal Feelings of sadness/loss Weight problems Stress Anxiety/tension/worry Panic attacks Heart racing Chest pain/heaviness Chills/hot flashes Tingling/numbness Pain Fear of dying Fear of going "crazy" Nausia Fears/phobias Obsessions/Compulsions Thoughts racing Disorganization Procrastination Can't hold onto an idea Anger Frustration Suspiciousness/Mistrustfulness Problems trusting others Easily irritated annoyed Aggressiveness Perfectionist behavior Lying Making/keeping friends Arguing with others
  • Performing unusual rituals or habits Arguing with others Impulsiveness Excessive behaviors (spending, gambling, sex, etc.) Thinking, seeing, believing, hearing unusual things Sexual problems Sexual problems Shyness Lack of social skills Lack of social support (family/friends) Stealing Strange, weird, or peculiar behavior Confusion/Can't think clearly Feeling "not real" Feeling detached from yourself Feeling "hyper" Financial problems Grief/bereavement Health problems Impact of your problems on others Losing track of time Problems with memories Unpleasant thoughts that won't go away Problems with memory Bothered by recurrent thoughts Job/career problems or indecision Destruction of property Self-criticism Family problems Marital relationship problems Parent/child problems Use of alcohol Use of drugs Blackouts Physical abuse Trouble with the law Experienced trauma Witnessed trauma Loss/death of someone close Other: Please specify below
  • Apartment Condo/Townhouse House Mobile Home Rooming house Untitled Option
  • Yes No
  • IF YOU ANSWERED YES, please complete the following section:

    Current Counseling/Therapy

  • Dates - Name of Professional - Address - Treatment Type
  • Please provide information regarding previous treatment you have received from a counselor, psychologist, psychiatrist, or other medical or mental health professional for this or other problems:

  • Dates - Name of Professional - Address - Treatment Type - Why treatment ended
  • Yes No

  • Date(s) - Name of hospital or facility - Address - Reason for Hospitalization

  • Dates of illness - Condition - Treatment - Results

  • Beginning date - Medication - Dose - Frequency of dose - Condition Treated

  • Date(s) - Type Used - Frequency of Use - Amount Typically Used - When ended (if applicable)
  • Please carefully read the statement below
    I understand that I am responsible for all fees for services provided to me. I have read, understand, and agree to comply with the fee policies, and the No Show/Cancellation Policy. I also acknowledge I have read the Consent for Treatment form and the Notice of Privacy Practices for Protected Health Information. By signing and submitting this document, I indicate that I have reviewed, understand, and agree to comply with the policies in this disclosure statement/agreement, and that I consent to treatment for myself or my child.

  • If you are signing for someone under age 18
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