Therapy Intake Form

I look forward to working with you.

Please provide the following information for my records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality as our therapy. If any given question does not apply to you, please put down “n/a” or “none.”

You will also need to confirm at the end that you have read the Good Faith Estimate Disclosure. 

PATIENT DETAILS

* indicates a required field

  • PATIENT INFO / BACKGROUND

  • MM slash DD slash YYYY
  • (necessary for billing)
  • (from your insurance card)

  • HEALTH / SOCIAL / LEGAL HISTORY

  • (please check all that apply)

  • HOSPITALIZATION HISTORY

  • PROFESSIONAL / OCCUPATIONAL HISTORY

  • FAMILY MENTAL HEALTH HISTORY

  • OTHER INFORMATION

    Please provide as many answers as possible in this section.

  • DIET / LIFESTYLE / NUTRITION

    Please provide as much detail as possible in this section.
  • This field is for validation purposes and should be left unchanged.

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