Dynamic Counseling: New patient Intake form
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Patients first name *
Patients last name *
email address *
Telephone number *
Date of Birth *
What type of therapy are you interested in? *
What is your gender? *
What is your orientation?
Do you have a current diagnosis? *
Have you had therapy before? *
If you have had therapy before please provide details
Have you ever been hospitalized for mental health? *
If you have ever been hospitalized for mental health please provide details?
Please check any that you are currently experiencing or have experienced in the last 30 days
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Any current mental health medications? *
Do you have a history of trauma *
What is your relationship status *
Are you requesting a specific type of therapy? If so please identify.
Do you have a gender preference for your therapist? State yes or no. If yes please identify. *
Do you have health insurance with mental health benefits? *
If you have health insurance please provide the name of the company, ID number and the provider number from the back of the card.
What is your address? *
What is your availability for appointments? *
Day and time of preferred appointment? please provide as many options as possible *
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