Living Springs Intake Form

Living Springs Psychotherapeutic Services

11145 Tampa Avenue, Suite 12B • Porter Ranch, CA 91326 • www.lspsych.com

Telephone 818-701-0107
FAX (818) 832-4298

Date

Personal Information

Name

Street Address

City, State, Zip

Date of Birth

Cell Phone

May we leave a message?

Yes No

Other Phone

Email

May we leave a message? Please Note: Email correspondence is not considered to be a confidential form of communication.

Yes No

In the event of an emergency, who do you give Dr. Williams permission to contact?

First and Last Name

Relationship to You

Phone Number

Your Gender

Man

Woman

Non-binary

None of the above, I identify as:

If you checked "None of the Above", you identify as:

Sexual Orientation

Heterosexual/Straight

Gay

Lesbian

Bisexual

Queer

Not sure

Other (please feel free to explain below)

Explanation

Are you currently employed?

Yes

No

If yes, please describe.

Are you a student?

Yes

No

Relationship Information

Check All Boxes That Apply Include Dates Below

Single

Domestic Partnership

Married

Separated

Divorced

Widowed

Do You Have Children?

Yes

No

If so, how many?

1

2

3

4

5 or more

Names and Ages of Your Children

Your Reason for Seeking Therapy

What do you hope to accomplish in therapy?

Is there anything else you would like to share before your therapy begins?

Health Information

Have you previously received any type of mental health services?

No Yes

If yes, name and date of therapist/practitioner.

Are you currently taking any prescription medication?

No Yes

If yes, please list.

Have you ever been prescribed psychiatric medication?

No Yes

If yes, please list and provide dates.

How do you rate your current physical health?

Poor

Unsatisfactory

Satisfactory

Good

Very Good

Please list any specific health problems you are currently experiencing.

How do you rate your current sleeping pattern?

Poor

Unsatisfactory

Satisfactory

Good

Very Good

Please list any difficulties you experience with your appetite or eating.

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

Yes

No

If yes, for how long?

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

Yes

No

If yes, for how long?

Are you currently experiencing any chronic pain?

Yes

No

If yes, please describe.

How often do you drink alcohol?

Never

One time per week

1-6 times per week

Every day

How often do you engage in recreational drug use?

Never

Daily

Weekly

Monthly

What do you consider some of your strengths?

What do you consider some of your weaknesses?

Who referred you to our office?

Your information will be encrypted.

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