Patient Intake & Contact

1

Personal Information

First Name *

Middle Name

Last Name *

Date of Birth *

Last 4 of SSN

Gender *

Pronouns

Marital Status

2

Contact Information

Street Address

City

State

ZIP Code

Primary Phone *

Secondary Phone

Email Address

Preferred Contact Method

3

Emergency Contact

Emergency Contact Name *

Relationship to Client

Emergency Contact Phone *

Emergency Contact Address

4

Referral Information

Referral Source

Referring Agency/Person Name

Referral Reason

5

Legal Status

Currently on Probation

Yes No

Currently on Parole

Yes No

Pending Legal Charges

Yes No

Court-Ordered Treatment

Yes No

If yes to any above, provide details

6

Insurance & Payment

Insurance Provider

Employment Status

Insurance ID / Policy Number

Group Number

Policy Holder Name (if different)

Policy Holder Date of Birth

Employer (if applicable)

7

Presenting Concerns

Primary Reason for Seeking Services *

How long have you been experiencing these concerns?

Previous mental health treatment?

Yes No

If yes, please describe previous treatment

Current Medications

Current Therapist or Psychiatrist

8

Substance Use History

History of Substance Use

Yes No

Currently in Recovery?

Yes No

If yes, substances used (select all that apply)

Alcohol Cannabis Opioids Stimulants Sedatives Hallucinogens Other

Previous treatment for substance use?

Yes No

9

Medical History

Current Medical Conditions

Allergies

History of Head Injury or Seizures

Yes No

10

Safety Screening

Currently experiencing suicidal thoughts?

Yes No

Currently experiencing self-harm urges?

Yes No

Thoughts of harming others?

Yes No

History of suicide attempts?

Yes No

If yes to any above, please provide additional details

Do you have a safety plan?

Yes No

11

Consent & Acknowledgment

Electronic Signature *

Date *

Patient Intake Form

Personal Information

Contact Information

Emergency Contact

Referral Information

Legal Status

Insurance & Payment

Presenting Concerns

Substance Use History

Medical History

Safety Screening

Consent & Acknowledgment

Intake Form Submitted

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