Brooke-Randolph, LLC Intake form
Completing this will not schedule appointment. If you have not already scheduled an appointment, please do so at
Date of birth
(if married or engaged)
Permission to leave a message at this number?
check all that apply
Reason for seeking services
Goals for counseling
Previous counseling experience - Where? With whom? How did it go?
Concerns about counseling
Any questions for the first session?
How did you find me?
social media (Facebook, twitter, etc.)
web search (Google, Bing, etc.)
referred by another professional
referred by a friend or family member
Health History and Habits
Primary Medical Provider/Family Doctor
Address for PMP/doctor
Phone for PMP/doctor
When was your last exam?
List any medical diagnoses
Surgeries or hospitalizations, including psychiatric hospitalizations
please include dates and hospital name
include dose, frequency, and prescribing physician
Average hours of sleep per night
Glasses of water per day
Nutritional level of your diet
Caffeine per day
include if coffee, soda, tea, tablets, etc
type and frequency
Alcoholic drinks per week
types, intensity, frequency per week
History or current illegal drug use
including misuse of prescriptions
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