Intake for Holistic Psychotherapy
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Full Name *
Birthdate *
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Address *
Please name 2 Emergency contacts, their relationship to you, and their number *
What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can *
What are your goals for counseling? *
Have you seen a mental health professional before? *
Specify all medications and supplements you are presently taking and for what reason.
If taking prescription medication, who is the prescribing MD? Please include type of MD, name and phone number.
Who is your primary care physician? Please include type of MD, name and phone number.
Do you drink alcohol? *
Do you use recreational drugs? *
Do you have suicidal thoughts? *
Have you ever attempted suicide? *
Do you have thoughts or urges to harm others? *
Have you ever been hospitalized for a psychiatric issue? *
Is there a history of mental illness in your family? *
If you are in a relationship, please describe the nature of the relationship and months or years together.
Describe your current living situation. Do you live alone, with others. With family, etc...
What is your level of education? Highest grade/degree and type of degree.
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What is your current occupation? What do you do? How long have you been doing it?
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Please check any of the following you have experienced in the past six months
Please check any of the following you have experienced in the past six months
What else would you like me to know?
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