Potential New Patient Intake

First and last name

(of potential patient)

Person Completing Form and Relation to Potential Patient

(leave blank if not applicable)

Date of Birth

Home Phone

Cell Phone

Email Address

Who referred you?

My Therapist Primary Care Provider Medical Specialist Friend Family Member Psychology Today Google/Other Online Search

Therapist's Name

(leave blank if N/A)

Reason for Referral/Seeking Help

Current Psychiatric Medications

(write none if N/A)

I have been hospitalized for psychiatric reasons

Yes No

Brief Description

I have attempted suicide

Yes No

I have a history of substance use/abuse check all that apply

Yes

I have been clean/sober for > 1 year

I have been in recovery for > 5 years

I currently use substances but don't believe I really have a problem

Drug/Alcohol Treatment check all that apply

None

Inpatient- Past

Inpatient-Recent/In Past Year

Outpatient- Past

Outpatient -Current

Brief Description

Current Legal Issues (CPS, DWI, Probation/Parole, Divorce, etc.)

Yes No

Brief Description

Is a lawyer or judge suggesting or requiring treatment?

Yes No

Is your employer/school requiring or suggesting treatment?

Yes No

Medical Problems/Issues

Additional or Clarifying Information

Enter anything here that you'd like Mr. Sharpe to know that is not covered above

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