New Patient Intake Form printable pdf download

New Patient Intake Form

NEW PATIENT INTAKE FORM

Full Name:

Preferred Name:

Phone #:

Email:

Is it safe to contact you at the number above?

QUESTIONS

Yes No

Have you been in therapy before?

Are you committed to treatment?

Are you currently on medication?

Do you have any medical problems?

If so, list here:

Do you experience hallucinations?

Are you sexually active?

Do you experience suicidal thoughts?

Do you have pets?

Do you have a known mental illness?

Have you been convicted of a crime?

If so, list here:

Are you in a relationship?

Do you speak English fluently?

What are you hoping to achieve through therapy?

Do you have any concerns you would like me to know about?

I hereby certify that I have read this therapist’s patient disclosure agreement as well as

all other documents provided. I understand the contents of these documents and agree

to the terms set forth therein.

Patient Signature:

New Patient Intake Form