Dynamic Counseling: New Patient Intake Form
Name of person completing this form *
Patients first name *
Patients last name *
email address *
Telephone number *
Date of Birth *
MM
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DD
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YYYY
What type of therapy are you interested in? *
What is your gender? *
Do you have a current mental health 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 *
Any current mental health medications? *
Do you have a history of trauma *
What is your relationship status
Clear selection
Briefly describe the reasons for seeking therapy at this time. *
Do you have a gender preference for your therapist? State yes or no. If yes please identify.
Do you have health insurance? *
If you have health insurance please provide the name of the company, plan name, ID number, group number and the provider number from the back of the card.
What is your address? *
Availability or day/time of preferred appointment? Please provide as many options as possible *
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