Therapy Intake Form

Emergency Assistanace

If this is an emergency, call:

9-1-1
Crisis Line: 9-8-8
National Suicide Prevention Lifeline: 1-800-273-8255
Maryland's Helpline: 2-1-1

Client Information

First Name

Last Name

Date of Birth

Gender

Phone Number

Email address

Address 1

City

State

Zip Code

Can we contact you by email or phone?

Phone Email Both

If no, what is your preferred method of communication?

Personal History

What is your highest level of education

Are you currently employed?

Yes No

If yes, what is your current occupation?

1. Do you use drugs?

Regularly Occasionally No

2. Do you smoke?

Regularly Occasionally No

3. Do you drink alcohol?

Regularly Occasionally No

4. Do you drink caffeine?

Regularly Occasionally No

5. Do you gamble?

Regularly Occasionally No

6. How often do you get a full night of sleep? 7-8 hours

Regularly Occasionally No

7. Do you exercise?

Regularly Occasionally No

8.Do you have a healthy and balanced diet?

Regularly Occasionally No

9. How often do you have time for fun and recreational activites?

Regularly Occasionally No

Is there anything else regarding your personal history that we should be aware of?

Emergency Contact

First Name

Last Name

Phone Number

Relationship

In case of an emergency, do we have permission to contact this person?

Yes No

Medical History

Have you previously received therapy

Yes No I can't remember

If yes, what is the therapist's name?

Have you previously been prescribed psychiatric medication?

Yes No I can't remember

If yes, what medications are you currently taking?

Are you pregnant?

Yes No

If yes, how far along?

Is there anything else regarding your medical history that we should be aware of?

Family History

Is there anything regarding your relationships you would like us to be aware of?

Do you have any children?

Yes No

If yes, briefly describe your relationship with your children

Briefly describe your relationships with your parents

Do you have any siblings

Yes No

Briefly escribe your relationship with your siblings

Is there anything else regarding your family history that we should be aware of?

Reasons for Visit

For Couple Therapy, please enter partner's info:

Partner's Full Name

Partner's Phone Number

Partner's Email Address

*For Family Therapy, please enter each family member's info:

Please enter each family member name and age

Describe the reasons you are seeking therapy.

Describe any goals or outcomes you hope to achieve from therapy.

Describe any significant life changes or stressful events that you have recently experienced.

Is there anything else you'd like to tell us about?

Scheduling with Baiden & Associates

Therapy Location

Telehealth In- Person Both Options

If you have insurance, we will send you a verification invite through Alma Insurance Type: Aetna, Cigna and Optum

Insurance

Alma (Aetna and Optum)

Private Payment Both Options EAP

EAP authorization code

If you are using EAP, please fill this information

Approved number of sessions

If you are using EAP, please fill this information

Effective dates

If you are using EAP, please fill this information. Example 1/2/2020-1/2/2021

Please verify below:

I verify that I am the person seeking services for myself or have legal authority to consent for a minor in my care.

I understand it is the policy of Baiden & Associates LLC to have consent from both parents before entering into services for a minor.

I understand that Baiden & Associates LLC may accept few forms of insurances payments and I can seek reimbursement directly from my insurance company.

Your information will be encrypted.

Baiden & Associates LLC

Baiden & Associates LLC is the leading counseling and supervised visitation services in Maryland, Virginia, and Washington, D.C. We provide quality mental health care rooted in evidence-based practice, empathy, and respect for Individuals, couples, and families. Our experienced service providers will make you feel welcomed, understood, accepted, and empowered as you embark on your journey to a full and meaningful life.