Online Intake Form Please fill in the information below and return by submitting using the button at the bottom of the form. Please note: information provided on this form is protected as confidential information. To read the Confidentiality Statement please click on this sentence. I read and understand the Statement of Confidentiality - please check thebox below First Name Last Name Date For Israeli Clients only תעודת זהות Parent/Legal Guardian (If under 18) Address Home Phone May I leave a Message Yes No Cell Phone May I leave a Message Yes No Work/Other Phone May I leave a Message Yes No Email May I leave a Message Yes No Date of Birth Age Gender Marital Status: Never Married Domestic Partnership Married Separated Divorced Widowed Do you have Children? Yes No Do They Live With You? Yes No If You Have Children, please list names and ages: Emergency Contact Person Relationship to Client Emergency Contact Persons' phone number Emergency Contact Persons' email Referred by (if any): Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No Previous therapist /practitioner Are you currently taking any prescription medications Yes No If yes please list Have you ever been prescribed psychotropic medications? Yes No If Yes, please list and provide dates:e 1. How would you rate your current physical health? Poor Unsatisfactory Satisfactory Good Very Good Please list any specific health problems you are currently experiencing: 2. How would you rate your current sleeping habits? Poor Unsatisfactory Satisfactory Good Very Good Please list any specific sleep broblems you are currently experiencing: 3. How many times a week do you generally exercise? What type of exercise do you participate in? 4. Please list any difficulties you experience with your appetite or eating problems: 5. Are you currently experiencing overwhelming sadness, grief, or depressions? Yes No If Yes, for approximately how long? 6. Are you curently experiencing anxiety, panic attacks or have any phobias? YesNo If Yes, when did you begin experiencing this? 7. Are you currently experiencing any chronic pain? Yes No If yes, please describe: 8. Do you drink alcohol more than once a week? Yes No 9. How often do you engage in recreational drug use? Daily Weekly Monthly Infrequently Never 10. Are you currently in a romantic relationship? Yes No If yes, How long? On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship? 11. What significant life changes or stressful events have you experienced recently? Alcohol/Substance Abuse in the Family? YesNo Relation (father, mother, uncle, etc.) Anxiety in the Family? YesNo Relation (father, mother, uncle, etc.) Depression in the Family? YesNo Relation (father, mother, uncle, etc.) Domestic Violence in the Family? YesNo Relation (father, mother, uncle, etc.) Eating Disorders in the Family? YesNo Relation (father, mother, uncle, etc.) Obesity in the Family? YesNo Relation (father, mother, uncle, etc.) Obsessive Compulsive Behavior in the Family? YesNo Relation (father, mother, uncle, etc.) Schizophrenia in the Family? YesNo Relation (father, mother, uncle, etc.) Suicide Attempts in the Family? YesNo Relation (father, mother, uncle, etc.) 1. Are you currently employed? Yes No If Yes, what is your current employment situation? Do you enjoy your work? Is there anything stressful about your current work? 2. Do you consider yourself to be spiritual or religious? Yes No If yes, describe your faith or belief. 3. What do you consider to be some of your strengths? 4. What do you consider to be some of your weaknesses? 5. What would you like to accomplish out of your time in therapy/counseling? Send