Intake Form

Bucks County Anxiety Center

Please correct the errors described below.

Contact Information

Emergency Contact

This information is requested in the event of a psychiatric emergency. No information will be given to anyone about your treatment status or appointments without your expressed permission.

Referral Source

Working with Your Therapist

Medical Information

Other Specialists you see
(ex: PT, OT, alternative medicine, psychiatrist, pain management)

Add additional specialist

Substance Use

Patient Safety Screener

Because some topics are hard to bring up, we ask these same questions of everyone.

High Risk Activities

Please indicate if you’ve ever done any of these activities, how often, and whether it’s happening now or happened in the past.

Background Information

Developmental and Educational Information

  • Must be filled out for all children and teens.
  • Please complete if you are a young adult (up to age 25) who has ever been diagnosed with ADHD, a learning difference, Asperger’s, sensory processing disorders, or any issue impacting your ability to make it through school easily and/or make friends.

Notice of Privacy Practices
HIPAA Acknowledgement/Consent

I hereby acknowledge that I can print off a copy of Bucks County Anxiety Center’s Privacy Practices from the website. All of the providers at Bucks County Anxiety Center follow the same privacy/HIPAA practices.

The practice HIPAA policy is available online at 24/7 for your reference.

In addition, I hereby consent to the use and disclosure of mine and/or my child’s personal health information for the purposes of treatment, payment, and health care operations.

Your information will be encrypted.