Intake Form

Please provide the following information and answer the questions below. Please note: Information you provide her is protected as confidential information.

Intake Form

Name(Required)
Name of parent/guardian (if under 18 years):*(Required)
MM slash DD slash YYYY
Address(Required)
Referred By (if any):*
Have you previously recieved any type of mental health services (psychotherapy, psychiatric services, etc.)?(Required)
Are you currently taking any prescription medication?(Required)
Have you ever been prescribed psychiatric medication?(Required)
1. How would you rate your current physical health? (select one)(Required)
2. How would you rate your current sleeping habits?(Required)
5. Are you currently experiencing overwhelming sadness, grief or depression?(Required)