New Client Intake Form* indicates required fields Your Name * First Name Last Name Today's Date * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email Address * OK to leave email message? * Yes No Phone * Country (###) ### #### OK to leave voicemail message? * Yes No Date of Birth * MM DD YYYY Occupation * Relationship Status: * Single Partnered Married Divorced Separated Widowed Who may I contact in case of emergency? * First Name Last Name Phone * Country (###) ### #### Relationship to You: * How did you find us? * Internet search Referral Other If referred, by whom? REASON FOR SESSION * Briefly describe your reason(s) for the session: What have you already done to address this? * What are your hopes for your future? * YOUR HISTORY * Please list important past or current medical or physical issues: Are you currently in the care of a physician or mental health professional? * Yes No If yes, please write their name(s) & phone number(s): May I contact them? Yes No Are you currently taking prescribed medication? * Yes No If prescribed medication is for mental, emotional, or sleep-related issues, please list medications and dosage: Do you have a history of: * (Check all that apply) Suicide Depression Addiction Mental Hospitalization Sexual, physical or emotional abuse Childhood violence or neglect Domestic violence Are you involved in any current or pending civil or criminal litigation, lawsuit, divorce or custody dispute? * (Please be informed that I do not take court or legal related cases.) Yes No Thank you!
