New Client Forms

If you’re a first-time client, please complete the New Client Intake Form prior to your first session.
You have two options to fill out the form:

  1. Complete the New Client Intake Form Online:  You may complete the client intake form online below.
  2. To Download and Print the New Client Intake Form:  If you prefer to download and print the forms please use the links below.  Fill the forms out and bring the completed forms to your first session.
Click to download New Client Intake Form Click to Download Limits of Confidentiality Policy Click to Download Cancellation/Rescheduling Policy

If you would like me to coordinate care with another provider (for example, your psychiatrist, endocrinologist, etc.), please download and complete this form:

 Consent to Release Information Form

New Client Intake Form

Please provide the following information and answer the questions below.   Please note: information you provide here is protected as confidential information.

First Name: *
Last Name: *
Name of Parent or Guardian if under 18 yrs old:
Birth Date: *
 /  / 
Age: *
Gender:
Marital Status:
Please list names and ages of any children:
Address: *
Primary Phone: *
-
May we leave a message?:
Cell Phone:
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May we leave a cell phone message?:
E-mail Please note: Email correspondence is not considered confidential: *
Referred By: *
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?: *
Are you currently taking any prescription medication?: *
If yes, please list medications and dates taken:
Have you ever been prescribed psychiatric medication?: *
If yes, please list psychiatric medications and dates taken:
How would you rate your current physical health?: *
Please list any specific health problems you are currently experiencing::
How would you rate your current sleeping habits?: *
Please list any specific sleep problems you are currently experiencing:: *
How many times per week do you generally exercise?: *
What types of exercise to you participate in:: *
Please list any difficulties you experience with your appetite or eating patterns.: *
Are you currently experiencing overwhelming sadness, grief or depression?: *
If yes, for approximately how long?:
Are you currently experiencing anxiety, panic attacks or have any phobias?: *
If yes, when did you begin experiencing this?:
Are you currently experiencing any chronic pain?: *
If yes, please describe?:
Do you drink alcohol more than once a week?: *
How often do you engage in recreational drug use?: *
Are you currently in a romantic relationship?: *
If yes, for how long?:
On a scale of 1-10, how would you rate your relationship?:
What significant life changes or stressful events have you experienced recently?: *

In the section below identify if there is a family history of any of the following.

  1. If no one in your family has experienced the item listed, please leave it blank.

  2. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

Alcohol/Substance Abuse:
Anxiety:
Depression:
Domestic Violence:
Eating Disorders:
Obesity:
Obsessive Compulsive Behavior:
Schizophrenia:
Suicide Attempts:

ADDITIONAL INFORMATION:

Are you currently employed?: *
If yes, what is your current employment situation?:
Do you enjoy your work? Is there anything stressful about your current work?:
Do you consider yourself to be spiritual or religious?:
If yes, describe your faith or belief::
What do you consider to be some of your strengths?:
What do you consider to be some of your weaknesses?:
What would you like to accomplish out of your time in therapy?: *