Intake Form

RESOLUTIONSTHERAPY

PSYCHOTHERAPY * COUNSELING * CONSULTATION

Intake Form

ResolutionsTherapy
Intake Information - Please fill out and press Submit

Please provide the following information for our records. This data is held as privileged and strictly confidential information, as is all information in our practice. Leave blank any question you would rather not answer. Fill it in online and then click the SUBMIT button and it will be transmitted to our office.

If you are making an office visit, or wish to mail us the completed form, you may print out the form which you can download HERE, and fill it in at your leisure, allowing you to bring it into the office in person, or just drop it in the mail.

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Today's Date:
NAME (last, first, MI): *
Name of Parent/Guardian (if client is a minor):
Gender:
Date of Birth: *
Age:
Marital Status:
List children & their ages:
Local Address: *
Home Phone *
May we leave a message?:
Cell Phone:
May we leave a message?:
E-mail: *
May we leave an E-mail message?:
Referred by:: *
Are you currently receiving psychiatric servces, professional counseling or psychotherapy elsewhere?:
Current service provider's name:
Are you currently taking prescribed psychiatric medication (antidepressants or others)?:
If yes, please list:
If no, have you been previously prescribed psychiatric medication?:
If yes, please list:
	EMPLOYMENT INFORMATION
Are you currently employed?:
If yes, who is your current employer and position?:
If yes, are you happy at your current position?:
Please list any work-related stressors, if any:
	RELIGIOUS / SPIRITUAL INFORMATION
Do you consider yourself to be religious?:
If YES, what is your faith?:
If NO, do you consider yourself to be spiritual?:
	FAMILY MENTAL HEALTH HISTORY Has anyone in your family (either immediate members or relatives) experienced difficulties with the following areas? Select all that apply.
	Depression
	Bipolar Disorder
	Anxiety Disorders
	Schizophrenia
	Panic Attacks
	Alcohol / Substance Abuse
	Eating Disorders
	Learning Disabilities
	Suicide Attempts
	Trauma History
	HEALTH AND SOCIAL INFORMATION
How is your physical health at the present moment?:
Please list any persistent physical symptoms or health concerns (such as chronic pain, headaches, diabetes, high blood pressure, cancer, heart condition, etc.): *
Are you having trouble with your sleep habits?:
	If yes, check all that apply from the choices below
	Sleeping too little
	Sleeping too much
	Poor quality sleep
	Disturbing dreams
	Other sleep problems
Specify what "other" sleep problems:
How many times do you exercise each week?:
About how many minutes each time?:
Are you having any difficulties with appetite or eating habits?:
	If YES, check all the boxes that apply to your situation
	Eating less
	Eating More
	Binge eating
	Making yourself throw up
Have you experienced significant weight change in the last 2 months?:
Do you regularly use alcohol?:
In a typical month, how often do you have 4 or more drinks in a 24-hour period?:
How often do you use recreational drugs?:
Have you had suicidal thoughts recently?:
Have you had such thoughts in the past?:
Are you currently in a romantic relationship?:
If yes, how long have you been in this relationship?:
On a scale of 1 to 10, with 10 being the best, how would you rate this relationship?:
In the last year, have you experienced any significant life changes or stressors? If YES, what were they?: *
	Have you ever experienced any of the following? Click all that apply.
	Extreme depressed mood
	Rapid speech
	Mood swings
	Extreme anxiety
	Phobias (extreme fears of something)
	Panic attacks
	Sleep disturbances
	Hallucinations
	Unexplained losses of time
	Alcohol / Substance Abuse
	Eating disorders
	Frequent body (physical) complaints
	Body image problems
	Repetitive thoughts
	Obsessions
	Repetitive behavior (frequent checking, hand washing)
	Homicidal thoughts
	Suicide attempts
	OTHER INFORMATION
What do you consider to be your strengths?:
What do you like most about yourself?:
What are effective coping strategies that you have learned?:
What are your goals for therapy?:
If you have any other information about your situation that you would like to submit, please enter it here:
	If you have completed the survey, please click SUBMIT. If you have not completed the required areas (red asterisk), you will be asked to do so before the survey is submitted. Thank you.

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