Client Intake Form Complete

Emergency Assistance

If this is an emergency, call:

Crisis Line: (911) 911-9111
911

Welcome!

This document is provided for informational and educational purposes only and should not be considered legal advice

Client Information

First name

Last name

Primary Contact Number

Alternate Contact Number

Email address

Date of birth

Address (Street and Number)

City

State

Zip

How may I contact you?

Phone Call

Text Message

Briefly, what brings you in today?

When did your problems first start? Within the last:

30 days

2-5 months

6-12 months

2 years

During adolescence

During Childhood

What areas of your life have been affected because of this problem?

Are you currently experiencing overwhelming sadness, grief, or depression?

Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks, or have any phobias?

Yes No

If yes, when did you begin experiencing this?

Please describe any major losses or traumas you have experienced:

What significant life changes or stressful events have you experienced recently?

What would you like to accomplish out of your time in therapy?

Medical History

Have you been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for your visit

Date of your last physical exam

Is there a chance that you are pregnant?

Yes No

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Do you have any allergies to medications?

Physical Health

How would you rate your current physical health?

Poor

Unsatisfactory

Satisfactory

Good

Very Good

How would you rate the quality of your sleep on a scale of 1 to 10 with 1 being extremely poor, and 10 being extremely excellent?

Emergency Contact Information

Add another emergency contact

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Client Intake Form Complete

Emergency Assistance

Client Information

Medical History

Physical Health

Emergency Contact Information

Emergency Assistance

Frank Truei

Founder, TRUEiCare