Jeffrey N. Chernin, Ph.D. MFT

Licensed Psychotherapist in Los Angeles

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Larchmont Village
Los Angeles, CA 90004

MFT# 37670

323-692-7781

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About Dr. Chernin
Psychotherapy Services
About Therapy and Counseling
Publications
- Relationship Book
- Blog
Resources
Contact

Confidential Intake Form

Name
Address
Street Address Address Line 2 City State ZIP Code
Birth Date
Cellphone
Email
Place of Employment
Work Phone
Spouse / Partner's Name
Emergency 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 Company
Phone
Subscriber ID #
Group #
Do you have additional insurance?
- Yes
- No
Why are you seeking counseling at this time? Please include current sources of stress
Mark 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 medications
- Yes
- No
If yes, please list
medication, dosage and reason for taking
Do you have a Primary Care Physician (PCP)?
- Yes
- No
If yes, PCP Name
Physician Phone Number
Have you had any previous psychotherapy, psychiatric care, or hospitalization for a mental disorder, or drug/alcohol problem?
- Yes
- No
Please provide the approximate dates and reasons you sought assistance
Acknowledgment
Please 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 Name
Date

About Dr. Chernin
Psychotherapy Services
About Psychotherapy and Counseling
Publications
Resources
Contact

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.

Acknowledgment