Intake Form
logo

Client Information

Name and Contact Information
Emergency Contact
Place of Service
Your Local Police Department Information
Demographic Information
Insurance Information
Do you have medical insurance?
Do you have a secondary insurance?
Presenting Problem
Current Symptoms
Medical History
Are you currently taking any medications?
What medications have you tried previously that did not work for you?
Do you have any medical conditions?
Mental Health History
Suicidal Ideations
Do you have any of the following:
Substance Use
Has anyone ever told you that you drink too much?
Have you ever tried any of the following?
Have you ever misused or abused prescription drugs?
Addition Information
Work
Do you enjoy what you do?
Marriage
Are you married?
Have you ever been divorced?
Do you have any prior marriages?
How many?
How many Dates of divorce/death?
 
Children
Do you have any children (including step-children)?
Religion/Spirituality
Family History
Were you adopted?
How old were you when you were adopted?
How old were you? Did they remarry?
Date of death
Date of death
Medical Conditions