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Intake Form - Adult

Personal Information

Full Name
Date of Birth
Email Address
Phone Number
Why are you seeking treatment
Current Insurance Provider

Past Psychiatric History

Previous Diagnoses
Past Psychiatric Hospitalizations
Current Psychiatrist
Current Therapist
Self-harming behavior (cutting, burning, etc)
Suicide Attempts

Family Psychiatric History

Any family history of psychiatric diagnosis or substance use

Medications (Psychiatric and medical)

Current
Past

Past Medical History

Past Medical History

Substance Use

Current
Past
Rehab history

Additional Information

Allergies
Legal History
Emergency contact
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