Helios Intake Form
Please provide the following information and answer the questions below.

Please note: all information you provide here is protected as confidential information.
If anything does not apply to you simply write N/A or leave blank. Feel free to skip any questions you are not comfortable answering or place a star next to anything you would like to talk about but do not want to write down.

Email address *
Date
MM
/
DD
/
YYYY
Last Name *
Your answer
First Name *
Your answer
Middle Initial
Your answer
Full Address (Street, City, State, Zip)
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Street Address *
Your answer
Phone (Preferred) *
Your answer
Ok to leave a message? *
Preferred Email *
Your answer
Emergency Contact and their relation to you
Your answer
Emergency Contact Information (Cell Phone, Work Phone, Email, Address)
Your answer
Primary Care Physician
Your answer
OBGYN (for women)
Your answer
What is your preferred Pharmacy (please indicated location with street address)?
Your answer
What are the problems you are seeking help for?
Your answer
What are your treatment goals?
Your answer
Are you currently in treatment with another provider?
If you are currently in treatment with another provider please indicate their name and phone:
Your answer
What are the most significant stressors in your life at this time?
Your answer
What is your employment status?
If employed, name of your employer:
Your answer
How would your describe your personality?
Your answer
Current Symptoms Checklist
Describe other if selected
Your answer
If YES, please answer the following. If NO, please skip to Your Medical History below: Do you currently feel that you don’t want to live?
How often do you have these thoughts?
Your answer
When was the last time you had thoughts of dying?
Your answer
On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?
Not very strong
Extremely strong
Would anything make it better?
Your answer
Have you ever thought about how you would kill yourself?
Is the method you would use readily available?
Have you planned a time for this?
Is there anything that would stop you from killing yourself?
Your answer
Do you feel hopeless and /or worthless?
Have you ever tried to kill or harm yourself before?
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