Confidential Intake Form NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birth DateCellphoneEmail Place of EmploymentWork PhoneSpouse / Partner's NameEmergency Contact (if other than spouse / partner)Please note: If you would like to be reimbursed by your insurance company, I will give you a form to send to your insurance company. In order to complete the form, please fill out the following information.Insurance CompanyPhoneSubscriber ID #Group #Do you have additional insurance?YesNoWhy are you seeking counseling at this time? Please include current sources of stressMark the box to the left for items that are troubling you Relationship Co-workers Family members Alcohol / drugs Eating / food Panic attacks Depression Suicidal thoughts Anger outbursts Racing thoughts Self-harm Mood swings Shopping Gambling Internet use Sexual activities Legal matters Debt / spending Career / work Isolation Friendships Anxiety Are you taking any medicationsYesNoIf yes, please listmedication, dosage and reason for takingDo you have a Primary Care Physician (PCP)?YesNoIf yes, PCP NamePhysician Phone NumberHave you had any previous psychotherapy, psychiatric care, or hospitalization for a mental disorder, or drug/alcohol problem?YesNoPlease provide the approximate dates and reasons you sought assistanceAcknowledgmentPlease review the Notice of Privacy Practices, Information and Office Policies (which includes the Good Faith Estimate) and the Telehealth Consent Form if applicable.Please check the following:* I acknowledge that I have reviewed the Notice of Privacy Practices, Information and Office Policies (including the Good Faith Estimate), and (if applicable) the Telehealth Consent Form. Full NameDate Date Format: MM slash DD slash YYYY