Intake Forms

Name

Email

How did you hear about me?

What do you hope to achieve during our sessions?

Date of Birth (yyyy-mm-dd)

Occupation

Emergency Contact - Name

Emergency Contact - Phone Number

Emergency Contact Relationship with you

Children (how many, how old)

Primary Care Physician

Physician - Phone Number

Serious Medical Illness/Accidents (describe and provide dates)

Are you currently on any medications? Are you currently on any medications?YesNo

Please list medications

Any past medications (please list)

Surgeries or operations (identify and give dates)

Any hospitalizations? Any hospitalizations?YesNo

When and for what reason(s)?

Have you ever been treated for depression/anxiety? Have you ever been treated for depression/anxiety?YesNo

By whom? By whom?InternistOB/GYNPsychiatristOther

Please list any medications prescribed

Have you had any previous counselling? Have you had any previous counselling?YesNo

With whom and when?

Are you now or have you ever been in the care of a psychiatrist? Are you now or have you ever been in the care of a psychiatrist?Currently seeing psychiatristHave previously seen psychiatristNever seen psychiatrist

Who, and when?

Have you ever been treated for alcohol or drug abuse? Have you ever been treated for alcohol or drug abuse?YesNo

When and where?

Have you been the victim of physical or sexual abuse? Have you been the victim of physical or sexual abuse?YesNo

Do you have suicidal thoughts? Do you have suicidal thoughts?YesNo

Have you had a suicide attempt? Have you had a suicide attempt?YesNo

Do you or have you ever had an eating disorder? Do you or have you ever had an eating disorder?YesNo

Do you have a history of infectious diseases? Do you have a history of infectious diseases?YesNo

Do you have any allergies? Do you have any allergies?YesNo

Do you or have you in the past used nicotine? Do you or have you in the past used nicotine?Yes, currentlyYes, in the pastNo

Do you have any personal spiritual practices (meditation etc)? Please describe.

Do you practice any physical activities that bring you into your body (yoga, tai chi...)? Please describe.