Intake Form (Adult)

If this is an emergency, call:

Client Information

First name

Last name

Cell phone number

Email address

Date of birth

Please provide your insurance ID below. If self pay selected, please write "N/A."

This will be used to confirm insurance is active and accepted by this provider prior to first session.

Please tell me a bit about the reason for seeking care.

Are you currently receiving psychiatric care?

Yes No

Please list any known medical and psychiatric diagnoses.

Please list any medications you are taking and for what conditions. Please include the dosage for any medications treating psychiatric conditions.

Have you ever been hospitalized for psychiatric reasons? If so, when was the last hospitalization?

When are you looking to start services?

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