Mental Health Intake Form
Please fill all the information on this form as it would help us understand your situation better. Thank You.
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Name *
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Email *
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Address *
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Phone number
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Date of Birth *
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Marital Status:
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Education
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What are the problems for which you are seeking help?
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What are your treatment goals?
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Current Symptom Checklist
If your symptoms are not included in the above checklist, please describe what you have been experiencing.
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Have you received counseling before? 
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CRISIS INFORMATION:
Any current suicidal thoughts, feelings or actions? if yes please explain (if the answer is no simply write no)
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Any current homicidal or assaultive thoughts feelings or anger control problems? if yes please explain (if the answer is no simply write no)
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Are you currently using any medication?
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Thank You. We will get back to you.
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