Dr. Thomas Lucking, Ph.D., LMFT
Psychotherapy Intake Form and Informed Consent
408.409.4167 (phone and text) doctorthomaslucking@gmail.com
Email address *
Demographics
Questions without a red asterisk next to them are optional
Full Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Age *
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Sex *
Marital Status *
Phone Numbers *
Enter best phone numbers to reach you along with a label stating what type of phone each number is. For example 555.555.1212 mobile (press enter for a new line for each number)
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Home Address
Street Address 1 *
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Street Address 2
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City *
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State or Province *
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Zip or Postal Code *
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Employment and Health Insurance
Employer
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Health Insurance Company
Your answer
Primary Person for Insurance
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Emergency Contact
Name *
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Phone *
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Relationship *
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Children
Please provide: NAME, AGE, LIVING at HOME (Y/N) (press enter for a new line for each child)
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Medication
Please provide: MEDICATION, REASON FOR TAKING, DOSAGE (press enter for a new line for each medication)
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Previous Therapists or Coaches
Please provide: NAME, INDIVIDUAL or COUPLE, DURATION (press enter for a new line for each entry)
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Presenting Issues
Select issues of concern for yourself, your loved one, or your relationship or family.
Multiple selections per issue are allowed.
Crisis Issues and Therapeutic Impediments
YES - My issue
YES - Partner or family member's issue
MAYBE - Me or another person's issue
Not a problem
SAFETY - Lack of safety in my relationships or life
TRAUMA - Unresolved emotional wounds or trauma from the past
COMMUNICATION - Extreme dysfunctional communication in primary relationships
ADDICTION - Clear and present addiction (behavioral or substance) impacting my or other's life in significant ways
ATTACHMENT - Childhood relationship wounds that are disrupting my present relationships
MEDICAL - Physical health issues that are significantly impacting my mental health
Mental Health
YES - My issue
YES - Partner or family member's issue
MAYBE - Me or another person's issue
Not a problem
Addiction
Anger
Anxiety
Depression
Family of origin
Finances
Forgiveness
Sexuality
Trauma
Values and Priorities
Physical Health
YES - My Issue
YES - Partner or family member's issue
MAYBE - My or another person's issue
Not a problem
Alcohol
Caffeine (coffee, tea, soft drinks)
Exercise
General health
Heart disease (heart attack, stroke, high blood pressure, tachycardia, etc.)
Illicit drug use
Memory
Migraines or other headaches
Neurological disease (seizures, epilepsy, brain tumors, etc.)
Nutrition
Sleep
Smoking (Nicoteine, Marijuana, other)
Stress management (meditation, exercise, social, spiritual)
Social Health
YES - My Issue
YES - Partner or family member's issue
MAYBE - My or another person's issue
Not a problem
Blended family
Cultural differences
Domestic violence
Gender roles, discrimination, and identity
Honesty, transparency, trust
In-laws and extended family
Intimacy non-sexual
Jealousy and infidelity
Parenting
Power differences and fairness
Relationship vision
Relationship wounds
Roles, chores, division of duties
Sexual intimacy
Social Interaction
YES - My Issue
YES - Partner or family member's issue
MAYBE - My or another person's issue
Not a problem
All or nothing thinking - inflexible rigid
Communication
Conflict - shuts down or attacks during conflict
Empathy - struggle to feel what others feel
Emotional identification - struggle to name what I am feeling
Emotional memory - struggle to remember how I felt in the past
Emotional nourishment - struggle to understand the need for emotional nourishment
Object of interest - struggle to move back and forth between multiple interests and responsibilities, tendency to laser focus on one thing
Relational problem solving - struggle with solving relational problems
Social interaction - struggle to respond to comments that are not direct questions or instructions
Spiritual Health
YES - My Issue
YES - Partner or family member's issue
MAYBE - My or another person's issue
Not a problem
Communal spiritual expression (church, synagogue, etc.)
Faith traditions
Parenting spiritual beliefs
Personal spiritual expression
Shared rituals
Spiritual values
Other areas of concern
Your answer
Acknowledge Acceptance *
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