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Pre Intake Form
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Home
About
Education
Services
Client information form
Pre Intake Form
Menu
Home
About
Education
Services
Client information form
Pre Intake Form
Join Telehealth session
Home
About
Education
Services
Client information form
Pre Intake Form
Menu
Home
About
Education
Services
Client information form
Pre Intake Form
Why are you seeking help now?
Have you seen or anyone in your family seen a mental health professional before? Have you or anyone in your family ever been hospitalized for psychiatric or substance abuse issues? If yes, who and when?
Please list any current or prior medical issues and list any medications that you are taking.
Are you now using or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication NOT prescribed?
Who are the members of your family and what kind of relationship do you have with them?
What are the social activities you participate in? What types of relationships do you engage in?
Are spiritual practices and cultural influences important to you? What are they?
What was family / home and school like for you while growing up?
What is your educational and work/volunteer experience?
What is your occupation right now and how long have you been doing it?
What is your current living situation. Do you live alone, with others, with family, ...?
Describe any stressors relating to your occupation?
Describe any current or past legal issues?
What strengths and abilities are you bringing to sessions? What needs or preferences do you have that will help us be successful?
Is there anything else you would like to tell me?
Please list an emergency contact (name, relationship, and phone number).
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