Client intake

Client Intake Form

Please note: We are only licensed in the state of Michigan. For Telehealth services you must be a resident and currently in the state of Michigan during your sessions.

New Client Intake Form

Please note any family history (in direct bloodline) of depression, anxiety, psychiatric problems, substance abuse, and alcoholism

Family Member Name	Relationship to Client	Diagnosed Issue

Did you serve in the military?

Yes

Repeater Field

Branch	Rank	Date Start of Service	Date End of Service

Currently Active?

Yes

Type of discharge?

Please list all of your medical conditions-- Include a brief description of the treatment. To add more use the (+) button.

Condition	Treatment

Experiencing Issues with Sleep?

Yes

Prescription medications

Name/Reason for Prescription	Dose	Date Prescription Started	Name of Prescribing Doctor

Are you under the care of a physician or other health care professional for any reason?

Yes

Is your child under the care of a physician or other health care professional for any reason?

Yes

Please list reason, duration and provider:

Note any allergies below (include medications, over-the-counter medications or recreational drugs)

Have you had any legal, job, educational or relationship issues due to alcohol, legal or illegal substance use and/or abuse?

Yes

Please list all illegal substances that you have used over your lifetime:

Please list any alcohol or illicit drugs that your child has used in the past 12 months:

Column 1

Have you been in counseling previously?

Yes

Has your child previously been in counseling?

Yes

Please indicate approximate dates of treatment, reason for treatment, your satisfaction with treatment outcome and therapist’s name (if known):

Describe any hospitalizations (medical or psychiatric). Give approximate dates and reason for treatment:

Do you have any physical disabilities and/or limitations?

Yes

Please Specify:

Does your child have any physical disabilities and/or limitations?

Yes

Please Specify:

Years of education completed:

Degrees Earned or Other Specialized Training

Please note any involvement with the legal system

Signature

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You authorize the release of any medical or other information necessary to process insurance claims

First Name

Last Name