Confidential Individual Intake Form
Please answer every question and submit.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone or Cell Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Our office typically communicates through "text" or "email". Do we have your permission to communicate with you by text and / or email?
*
Yes
No
Other
What is the specific reason for seeking counsel at this time?
*
How did you find Dr. Judith?
Referral (Who), Psychology Today, Focus on Family, Friend, Church, or ?
Date of Birth
-
Month
-
Day
Year
Date
Marital Status
*
Single
Married
Divorced
Separated
If you were previously married or separated, or considering ending a relationship, what is or was the reason?
*
Enter 0 if you have never been in a "relationship."
If previously married, how long were you together?
*
Months or years.
Are you in a "relationship" now?
*
Yes
No
Is there a history of relationship issues or behavioral patterns in your family?
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Yes
No
Other
What is your vocation?
*
If you are married, engaged, or have a live-in partner, what is their vocation? Enter 0 if this does not apply
*
Do you use alcohol
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Yes
No
Maybe
If you do use alcohol, how many drinks per day?
*
Do you use mood altering drugs (legal or otherwise)?
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Yes
No
If you do use mood altering drugs, what and how often
*
Confidential
Have you ever seen a professional counselor or therapist in the past?
*
Yes
No
Reason for seeing therapist in the past.
*
Confidential
Is there a history of mental health issues in your family? Explain
*
Do you have cravings that are hard to control?
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Yes
No
If yes, what?
On a scale of 0 to 10 (with 0 being abstinent and 10 being great) how would you rate your love life?
*
On a scale of 0 to 10 how important is spirituality to you?
*
What is your religious preference
blanks
On a scale of 0 to 10, how important is diet to you?
*
Do you sometimes feel depressed?
*
Yes
No
Are you currently depressed?
*
Yes
No
I'm not sure
Have you ever been physically beaten or sexually molested?
*
Yes
No
If yes, please describe the circumstances (confidential).
Confidential
Did you live with both your biological parents as a child?
*
Yes
No
How would you describe your childhood and upbringing?
*
Which of the following emotions have you or are you having difficulty controling?
*
Frustration
Loneliness
Hatred
Anger
Depression
Fear of death
Anxiety
Feeling of worthlessness
Suicide
Feeling unloved
Bitterness
Fear of hurting someone
Do you feel like you can express your emotions?
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Easily express
Suppress them
Other disregard how I feel
express some
It is not safe
My feelings are too painful to deal with
I have read and agree with the Privacy Statement as posted on the website.
*
Yes
I agree to treatment
*
yes
Signature
The typing of your signature is a legal representation of an actual signature.
Submit
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