AUBREY K. EWING, PH.D. & ASSOCIATES, P.A.
1230 So. Federal Hwy, Boynton Beach, FL 33435
ADULT CLINICAL INTAKE QUESTIONNAIRE
The questions on the following pages ask you to provide information about why you are seeking counseling or other psychological services. They ask about your general emotional and physical health, pertinent history, how you are feeling now, and what concerns are most important to you. The questionnaire gives your doctor/therapist a head-start in understanding how to be of help to you.
This information will become part of your confidential record with this office and will not be released to anyone without your written permission. Your answers to these questions are considered protected health information (PHI) and are relayed to our office by a secure, HIPAA compliant process. We are committed to ensuring your privacy and protecting our confidential relationship.