Intake Form

Emergency Contact

If coming as a couple please list someone other than your partner.
Emergency Contact: *

First Name Middle Initial Last Name
Relationship *
Contact Number *

Area Code Phone Number
Medical Providers

Please fill in available information
Primary Care Provider Name
Check here if you currently DO NOT have a Primary Care Provider and move on to the next section
Primary Care Provider's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of last Appointment with Primary Care Provider, estimate okay.

Month Day Year
Date
Psychiatrist or Medication Manager's Name
Check here if you currently DO NOT have a Psychiatrist or Medication Manager and move on to the next section.
Psychiatrist or Medication Manager's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of last Appointment with Psychiatrist or Medication Manager, estimate okay

Month Day Year
Date
Medications
Are you taking any medications, currently?

Yes No
If yes, please list them here.
If lengthy you may forward a full copy separately.
Allergies:
Who referred you? How did you learn about these services?
PHQ-9

Depression screening: (Please note: The PHQ-9 and the GAD-7 look very much alike but have different questions)
Over the last 2 weeks how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
2. Feeling Down, depressed or hopeless
3. Trouble falling asleep or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or over eating
6. Feeling bad about yourself or that you are a failure or have let yourself or family down
7. Trouble concentrating on things, such as reading or watching TV
8. Moving or speaking so slowly that others could have noticed. Or the opposite, being so fidgety that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself.
10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?
GAD-7

Anxiety Screening: (Please note, The GAD-7 and the PHQ-9 look alot alike, however the questions are different.)
Over the last 2 weeks how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?
Should be Empty:

Intake Form

Client Data Sheet

Medical Insurance Information

Emergency Contact

Medical Providers

Medications

PHQ-9

Over the last 2 weeks how often have you been bothered by any of the following problems?

GAD-7

Over the last 2 weeks how often have you been bothered by any of the following problems?