Psychotherapy Intake Form

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PSYCHOTHERAPY INTAKE FORM
Please provide the following information. All information will be protected and held confidential.
Name:__________________________________________________________________________
(Last)
(First)
(Middle Initial)
Age:__________
Birthdate:__________ Gender:
M
F
Other
Relationship Status:
Never Married
Married
Divorced
Separated
Widowed
Domestic Partnership
Please list any children, alive or deceased, and ages:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Home Address:
__________________________________________________________________________________________
(Street)
(City)
(State)
(ZIP)
Primary Phone #:_______________________________
Home
Cell
Work
Okay to leave a message?
Yes
No
Email: ________________________________________________________
Emergency Contact:________________________________________________________________________
(Name)
(Relation)
(Phone)
Referred by (ex: physician, friend, etc.):_______________________________________________________

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