top of page
About
Services
Anger Management
Forms & Booking
Disclosure
Intake Form
Client Registration
Book Now
Contact
More
Use tab to navigate through the menu items.
Free Consultation
Intake Questionnaire
Relationship Status
Single
Married
Divorced
Widowed
Domestic Partnership
In a relationship
Separated
Years in current occupation
Education (check highest completed)
Doctorate
Some College
Masters
High School
Bachelors
Other
Associates
Reason for visit
Have you ever received counseling/psychotherapy before?
Reason
Have you ever received a formal psychological evaluation?
Diagnosis
How would you rate your current physical health?
Poor
Satisfactory
Good
Excellent
Please list any health problems that you are currently experiencing:
How would you rate your current sleep patterns?
Poor
Satisfactory
Good
Excellent
Please list any sleep problems that you are currently experiencing:
How would you rate your current eating habits?
Poor
Satisfactory
Good
Excellent
Please list any eating problems that you are currently experiencing:
Current medications (include prescriptions, over the counter, and vitamins)
What are your goals for therapy?
What else would be useful for me to know?
Your Signature
Clear
Submit
bottom of page