Therapy Intake Form Patient Info / BackgroundName* First Last Date of Birth* Month Day Year Address* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Cell Phone*May I leave a message?* Yes No Home PhoneMay I leave a message? Yes No Email* Enter Email Confirm Email Age*Gender Marital Status Number of Children Who referred you to this practice? Are you currently in treatment with another mental health provider? Are you currently on any psychotropic medication (e.g. antidepressants, etc.)? If so, what are you currently taking? (please list medication name and dose)? Who is prescribing these medications for you? If you are not currently on psychotropic medication but you have been in the past, what were you on and who prescribed this for you? Have you had psychotherapy/counseling before? If so, who with? Are you on any medication at all (not just psychiatric)? If so, what and how much (and what is it treating)? Health / Social / Legal HistoryHow is your physical health? Any chronic physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.)? Any sleep problems? If so, please describe:Do you have a regular wellness/exercise routine? If so, please describe:Any problems with appetite or eating? If so, please describe:Do you regularly use alcohol? Other substances? If so, please describe (what, how often, how much).Have you ever been arrested/convicted/any D.U.I.s? If so, please describe:Do you ever thinking about killing yourself? Have you ever attempted to kill yourself? Please, describe:Are you having any relational problems? If so, please describe:What stresses you out at present/currently? Please, describe:Have you ever experienced any of the following? (Please check all that apply.) Select All Extreme depressed mood Wild mood swings Rapid speech Extreme Anxiety Panic attacks Phobias Sleep disturbances / hallucinations Unexplained losses of time Unexplained memory lapses Alcohol / substance abuse Frequent body complaints Eating disorders Body image problems Repetitive thoughts (e.g. obsessions) Repetitive behaviors (e.g. frequent checking, hand-washing, etc.) Homicidal thoughts Suicide attempt Hospitalization HistoryHave you ever been psychiatrically hospitalized? If so, was it voluntarily? Or was it involuntarily? When/where? Please, describe:When did the current symptoms start to surface? Was there a precipitating event (death, loss, break up, financial issues, etc) or did the symptoms seem to happen without provocation?Professional / Occupational HistoryWhat is your education level? What do you do for living? Family Mental Health HistoryHas any member of your immediate family received any psychiatric/psychological treatment? If so, please, describe (for what problem, what type of treatment)?Other InformationWhat is your first childhood memory? Please provide details such as who, what, when, etc.If you had to describe your mother in one word, what would it be? And now your father? How do you feel about yourself?How do you cope with moderate to severe stress?How do you respond to grief, loss, and/or disappointment?What do you hope to get from therapy?What do you read?What do you watch on TV?Do you have a meditation practice? What, if any, is your religious/spiritual background? Diet / Lifestyle / NutritionPlease provide basic information about your daily diet. Do you have food allergies? If so, what are they? Do you drink caffeine? If so, what type and how much? Do you eat processed foods? If so, provide examples.Were you breastfed or bottle fed as an infant? (If you do not know, please indicate that.) Are you vegetarian? Yes No If so, do you take vitamin B 12 supplement? If yes, what form (oral, iv, sublingual)? Do you take omega-3 fatty acid supplements? If yes, how much per day? Do you eat/drink dairy? If yes, how much per day? Do you eat gluten? If yes, how much per day? Have you had your thyroid tested in the last 6 months? If yes, please provide me with a copy of those results. What types of food do you crave? Sweet Savory Both Do you feel you have ample restraint to refrain from these cravings or do they feel out of your control?What was the culture of food in your household growing up?Do you suffer from eczema, rashes, etc.? If so, do you recall the treatment?Did you ever suffer from chronic ear infections? If so, do you recall how often you were put on antibiotics?Did you struggle with attention related issues in elementary school? Or hyperactivity? If so, how did your school and family help you to manage these symptoms?Is there anything else you feel I should know related to how nutrition and food impacts your life?Confirmation of Good Faith Estimate Disclosure: I have read the Good Faith Estimate Disclosure PhoneThis field is for validation purposes and should be left unchanged.