PLEASE READ THIS SECTION THOROUGHLY BEFORE STARTING THE INTAKE OR ANSWERING QUESTIONS.
Estimated time to complete all pages is approximately 10-20 minutes (possibly more) depending on required sections of the intake and provided that all requested information is available to you while completing this form (psychological and medical history, doctors name, address and phone number).
Please note: All the information you provide here is protected as confidential information on a secure and encrypted website that will only be viewed by the therapist.
"ALL" general intake questions are "REQUIRED" by the therapist for an accurate assessment. Although there are a lot of questions, all are very relevant and necessary for appropriate treatment.
The first section is for your information, for which you will have to agree and consent to treat.
Please also note that if you don't know an exact date on the physical, dental, hearing and vision exam questions, it is okay to estimate!
Financial Assistance questions are optional, and only required if requesting a sliding fee scale.
**If you are competing this intake for ESA Disability and Treatment Recommendation Letter Service, please be sure to complete all intake questions sections and the last/required ESA section in its entirety. Please note that you can skip the Financial Assistance section, as a sliding fee scale is not available with this service due to the additional clinical requirements and service. If you are not requesting ESA Letter Service, that section can be skipped.
PLEASE BE HONEST AND COMPLETE IN YOUR ANSWERS AND DO NOT SUBMIT AN INCOMPLETE OR FALSE INTAKE, AS IT WILL NOT PROVIDE THE THERAPIST WITH THE INFORMATION TO PROVE A COMPREHENSIVE AND ACCURATE ASSESSMENT!