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- Confidentiality Statement
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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. I have read and understand the Statement of Confidentiality.

First Name

Family 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

DOB

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:

Relation to client

Contact Phone number

Contact Email

Referred By (if any) or where did you hear about us?

Have you previously received any type of mental health services (psychothrapy, psychiatric services, etc.)?

Yes No

Previous therapist/practitioner

Are you currently taking any prescription medication?

Yes No

If yes, list Meds

Have you ever been prescribed psychiatric medications?

Yes No

Please list and provide dates

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 problems you are currently experincing:

3. How many times per week do you generally exercise?

What types 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 depression?

Yes No

If yes, for approximatley how long?

6. Are you currently experiencing anxiety, panic attacks or have any phobias?

Yes No

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, for how long?

On a scale of 1-10 (with 1 being poor and 10 beint exceptional), how would you rate your relationship?

11. what significant life changes or stressful events have you experienced recently?

In the section below, identify (by checking the answer) if there is a family history of any of the following. If yes, please indicate the family member's relationship in the space provided (e.g. father, grandmother, uncle, etc.

Alcohol/Substance Abuse

Yes No

Anxiety

Yes No

Depression

Yes No

Domestic Violence

Yes No

Eating Disorder

Yes No

Obesity

Yes No

Obsesive Compulsive Behavior

Yes No

Schizophrenia

Yes No

Suicide Attempts

Yes No

1. Are you 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 therapy?

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