Intake and Insurance

Please fill in all fields for yourself as an individual

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Todays Date: Date of Birth: Name: Gender: Spouse / Partner: Mailing Address: City: State: Zip Code: Email Address:

Home Phone:

Work Phone:

Cell Phone:

Marital Status:

Single Married Widowed Divorced Other

Select Payment Type:

Cash Pay Insurance EAP


Who referred you to Healing Dialogue LLC: Employer's / School's Name: Insurance Company: Insurance ID Number: Insurance Group Number:

Name, Phone & Relationship of a close friend/relative to alert in an emergency:

Co Pay / Session Fee:

DUE AT THE BEGINNING OF EACH APPOINTMENT

(Cash, Check, Credit Card)

Please pay your Therapist or the Office Manager directly

WE DO NOT MAKE REMINDER CALLS BEFORE APPOINTMENTS

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Adult information form

Fill in all applicable fields

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Present Problems and Conerns

Describe the problem that brought you here today:

Please check all the behviors and symptoms that you consider problematic:

Distractibility	Hyperactivity	Impulsivity
Boredom	Poor memory	Seasonal mood changes
Sadness/depression	Loss of pleasure/intrest	Hopelessness
Thoughts of death	Self-harm	Crying spells
Loneliness	Low self worth	Guilt/Shame
Fatigue	Change in appetite	Lack of motivation
Social withdrawl	Anxiety/worry	Panic attacks
Fear away from home	Social discomfort	Obsessive thoughts
Compulsive behavior	Aggression/fights	Frequent arguments
Irritability/anger	Homicidal thoughts	Flashbacks
Hearing Voices	Visual Hallucinations	Suspicion/paranoia
Racing thoughts	Excessive energy	Wide mood swings
Sleep problems	Nightmares	Eating problems
Gambling problems	Computer addiction	Pornography addiction
Parenting problems	Sexual problems	Relationship problems
Work/school problems	Alcohol/drug use

Are your problems affecting any of the following:

Handling everyday tasks	Work/School	Recreational activities
Self esteem	Housing	Sexual activity
Relationships	Legal matters	Health
Hygiene	Finances

Have you ever had thoughts, made statements, or attempted to hurt yourself? Yes No
If yes, please describe:
Have you ever had thoughts, made statements, or attempted to hurt someone else? Yes No
If yes, please describe:
Have you recently been physically hurt or threatened by someone else? Yes No
If yes, please describe:

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Family And Developmental History

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Relationship	Name	Age	Quality
Mother:
Father:
Stepmother:
Stepfather:
Spouse:
Sibling One:
Sibling Two:
Sibling Three:
Sibling Four:
Child One:
Child Two:
Child Three:
Child Four:

Family Mental Health Problems	Who?
Hyperactivity:
Sexually Abused:
Depression:
Manic Depression:
Suicide:
Anxiety:
Panic Attacks:
Obsessive-Compulsive:
Anger/Abusive:
Schizophrenia:
Eating Disorder:
Alcohol Abuse:
Drug Abuse:

Parents legally married or living together Parents temporarily separated Parents divorced or permanently separated
Mother remarried: Number of times: Father remarried: Number of times:
Check if you have experienced any of the following types of tramua or loss:

Emotional abuse	Sexual abuse	Physical abuse
Parent substance abuse	Teen pregnancy	Neglect
Violence in house	Crime victim	Parent illness
Placed a child for adoption	Lived in foster home	Multiple family moves
Homelessness	Loss of loved one	Financial Problems

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Previous Mental Health Treatment

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Type of Treatment	When?	Provider/Program	Reason
Outpatient Counseling
Medication (mental health)
Psychiatric Hospitalization
Drug/Alcohol Treatment
Self-help/Support Groups

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Substance Use History

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	Current Use (last 6 months)
Type	Used Substance?	Frequency	Amount
Tobacco
Caffeine
Alcohol
Marijuana
Cocaine/crack
Ecstasy
Heroin
Inhalants
Methamphetamines
Pain Killers
PCP/LSD
Steriods
Tranquilizers

	Past Use
Type	Used Substance?	Frequency	Amount
Tobacco
Caffeine
Alcohol
Marijuana
Cocaine/crack
Ecstasy
Heroin
Inhalants
Methamphetamines
Pain Killers
PCP/LSD
Steriods
Tranquilizers

Have you had withdrawl symptoms when trying to stop using any substances? If yes, please describe:

Have you ever had problems with work, relationships, health, the law, etc, due to your substance use? If yes, please describe:

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Medical Information

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Date of last physical exam:

Have you experienced any of the following medical conditions during your lifetime

Allergies	Chronic pain	Dizziness/fainting	High fevers
Sexually transmitted disease	Asthma	Surgery	Meningitis
Diabetes	Abortion	Headaches	Serious accident
Seizures	Hearing problems	Sleep disorder	Stomach aches
Head injury	Vision problems	Miscarriage

List of any CURRENT HEALTH CONCERNS:

Medication	Dosage	Date Prescribed	Prescribed By

Current over-the-counter medications (including vitamins, herbal remedies, etc):

Have you ever had allergies and/or adverse reactions to medications: Yes No

If yes, please list:

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Interpersonal/Social/Cultural Information

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Please describe your social support network (check all that apply):

Family Neighbors Friends Students Co-worker Support/Self-Help Group Community Group Religious/Spiritual Center
To which cultural or ethnic group do you belong?

If you are experiencing any diffculties due to cultural or ethnic issues, please describe:

How important are spiritual matters to you? Not at all Little Somewhat Very much
Would you like spiritual/religious beliefs to be incorporated into your counseling? Yes No

Please describe your strengths, skills, and talents:

Describe any special areas of interest or hobbies (art, books, physical fitness, etc):

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Miscellaneous Information

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Employment

Employer:
Position:
Length of time:
Job Duties:
Stress level of position: Low Medium High
Other jobs you have held:

Education

Are you currently attending school? Yes No

High School Graduate

OR

GED
Year:
Associates Degree Year: Major:
Undergraduate Degree Year: Major:
Graduate Degree Year: Major: