Intake Form (Adult)

Please correct the errors described below.

Intake Form

The purpose of this form (Intake Form) is to collect important information about your history and current symptoms, in your own words. We'll collect the basics, as well as information about your mental wellbeing, and your relational health. Please try to describe your situation as accurately as possible. Thank you!


Emergency Contact Information

Add another emergency contact

B. Relationship History

How do you experience yourself? Do you experience any heightened sensitivity with any sense (such as hearing or touch)? What's your relationship to the world? How do you experience the world? How do you move through the world, in your inner world? No right or wrong answer.

C. Trauma & Loss History

D. Learning & Education

E. Employment History

F. Social Relationships

G. Depression Assessment

Do you experience any of the following? Use the dropdown menu and select the best option.

H. Anxiety Assessment

Executive Function Skills

I. Medical & Mental Health History

J. Hormone/Reproductive Health

K. Self-Care Habits

L. Sleep Health

M. Medications

N. Primary Medical Provider

Thank you!

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