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Adult Intake Form
Sol Play Child Therapy Inc - Owned by Shirla de Magalhães, LMFT, RPT-S,RSP License 82947 - 8453 La Mesa Blvd, La Mesa, CA 91942- 619-797-6595 www.soltherapysandiego.com
Today’s Date
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Month
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Day
Year
Date
Referred by
Name
First Name
Last Name
Preferred pronoun:
He, Him, His
She, Her, Hers
They, Them, Theirs
Date of Birth
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Month
-
Day
Year
Date
Age
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Can Therapist contact you by (select all that apply):
Cell Phone
Text
E-mail
Mail
Relationship Status
Single
Married
Divorced
Separated
Widowed
Dating/In a Relationship
It's Complicated
Other
Do you have children? If yes please list names and ages.
Health Insurance
Policy #
Name of Primary Insurance Holder
Co-Pay
Deductible to be met
Has your deductible been met?
Yes
No
Not Sure
For Tricare Only: Social Security # of Sponsor
Primary Doctor
Primary Doctor Phone Number
Please enter a valid phone number.
Psychiatrist
Psychiatrist Phone Number
Please enter a valid phone number.
Emergency Contact:
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Currently Employed?
Occupation
Employer
Hours per week
Do you enjoy your work? Is there anything stressful about your current work?
Education:
High School
Some College
Associates
Bachelors
Masters/Graduate
PhD
Post Doctoral
Technical/Trade School
Other
Cultural Heritage:
Any Spiritual Practice?
What brings you to therapy?
Medical/Mental:
Date of Last Doctor's Visit
How would you rate your current physical health?
Very Good
Good
Satisfactory
Unsatisfactory
Poor
Please list any Medical concerns
Have you participated in therapy before?
Yes
No
Names of any previous therapists, dates of service, and briefly describe that experience.
Please list any current medication(s) you are taking, dosage, frequency.
Date of Last Psychiatrist Appointment (if applicable)
Please list any hospitalizations with dates.
How would you rate your current sleeping habits?
Very Good
Good
Satisfactory
Unsatisfactory
Poor
Please list any specific sleep problems you are experiencing:
How many times per week do you generally exercise?
What types or exercise do you like to engage in?
How would you rate your current eating habits?
Very Good
Good
Satisfactory
Unsatisfactory
Poor
Please list any difficulties you experience with your appetite or eating patterns:
How often do you drink alcohol?
How often do you engage recreational drug use?
Are you currently in a romantic relationship?
Yes
No
Sort of
If yes, for how long?
On a scale of 1-10, how would you rate your relationship?
What significant life changes or stressful events have you experienced recently
Current symptoms and impairments you have been experiencing and frequency
Often
Sometimes
Rarely
Never
Anger
Anxiety
Appetite Disturbance
Avoidance
Crying Spells
Decreased Energy
Delusions
Depression
Detachment
Difficulty with Children
Difficulty with Others
Dissociative States
Elevated/Manic Mood
Emptiness
Exaggerated Startle Response
Fears
Flashbacks
Hallucinations
Helplessness
Hopelessness
Hyperactivity
Impulsiveness
Increased Suspicions
Increased Neediness
Indecisiveness
Irritability
Lack of Interest
Nightmares
Obsessions/Compulsions
Oppositional/Defiant
Panic Attacks
Grief
Guilt
Intrusive Thoughts
Paranoia
Poor Concentration
Poor Self Esteem
Thoughts About Death
Thoughts About Harming Others
Sadness
Significant Weight Loss
Sleep Disturbance
Somatic Complaints
Self Harm
Suicidal Thoughts
Worthlessness
Additional Comments
Family Mental Health History In the section below, please identify if there is a family history of any of the following: Please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.…)
Family member(s)
Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behaviors
Schizophrenia
Suicide Attempts
Other:
Additional Comments about Family History:
What do you consider some of your strengths?
What do you consider some of your weaknesses?
What would you like to accomplish out of your time in therapy?
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