Psychology Intake Form Address CLIENT INFORMATION Marital StatusSingleMarriedDivorcedWidowedOther Preferred Contact Method PhoneEmailText EMERGENCY CONTACT INSURANCE INFORMATION (if applicable) Relationship to ClientSelfSpouseParentOther REFERRAL INFORMATION How did you hear about our practice?Online SearchReferralSocial MediaInsurance DirectoryOther PRESENTING CONCERNS MENTAL HEALTH HISTORY Have you previously seen a therapist?YesNo Have you ever been diagnosed with a mental health condition? YesNo Are you currently taking any psychiatric medications? YesNo Have you ever been hospitalized for mental health concerns? YesNo MEDICAL HISTORY Do you have any current medical conditions?YesNo Are you currently taking any non-psychiatric medications?YesNo SUBSTANCE USE Do you use alcohol?YesNo Do you use recreational drugs? YesNo Have you had concerns about substance use in the past? YesNo FAMILY & SOCIAL HISTORY Do you live alone?YesNo Family history of mental health concerns? YesNo CONSENT & SIGNATURE By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that this information will be used to guide my care and is confidential under HIPAA regulations. Client Signature: Clear Date Parent/Guardian Signature (if minor): Clear Date
