Intake form
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Today’s date *
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DD
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Your first name & last name  *
Which type of therapy are you looking for ?  *
Required
What is your phone number ? *
What is your address ? *
Which therapeutic method are you interested in trying ? ?  *
Required
What brought you to therapy? What  would you like to work on in therapy session ? (your presenting problems)  *
what is your gender identity ? 
What is your ethnicity ?
What is your religion and/or spiritual background  ?
What allergy do you have if any?  *
What physical problems do you have ? *
Do you have any primary doctor? If yes, what is your name of your doctor or clinic ? 
Which drug have you used before ? *
How often and how much do you use (drink)?  *
When have you become hospitalized before ? What happened to you ?  *
Have you ever thought that you would be better off dead or hurting your self ? If yes, when have you done that ?  *
Are you feeling suicidal or experiencing suicidal ideation right now? 
If yes, do you have means, intention and plan to commit suicide ? 
 *
Have your ever harmed someone physically ? 
If yes, when and how did occur ? 
 *
Are you currently thinking of harming someone ? 
If yes, do you have any means, intention and plan to do it ? 
 *
Any comment or additional information. 
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