Hello, and welcome to our link for New Client Forms!

If you have already contacted our office and scheduled an appointment, this link is designed to save you time during our initial interview.

On the following pages are two forms;  a one-page Insurance Information Form, and a three-page Pre-Intake Form.  These forms are NOT set up to be filled out online and electronically submitted.  Instead, print out this section (you can tell your printer to print out pages 2-5, so that you don’t get this page), fill it out before you come in for your first session, and then bring it in with you when you come in for your appointment.

This will allow for the best use of our time during the initial session, as there are many other questions that we will review during our initial meeting.  If you are not sure how to answer something, just leave it blank.  We will review all the information you have provided in these forms, so that if you need to clarify anything, you can do so at that time.

Thank you in advance.  Looking forward to working with you.

Name of client _____________________________         Birth date ______________

 If minor, name of parent or guardian ________________________________________

 Home phone (_______)_____________      Business phone (______)________________

 Cell phone(______)________________       Email _______________________________

 Address ______________________________________________________________

Whom may we thank for referring you? _(name)__________________________________

(address)___________________________________(tel)_________________________

 Marital status: Single ____  Married ____  Divorced ____  Widowed ____

 Social Security number ________-_______-_________

 Person financially responsible for this account _________________________________

 Relationship to client ____________________         Address (if different from client’s)

___________________________________________________________________

Insurance company name & address_________________________________________

_____________________________________   Insurance ID # ___________________

Subscriber’s name (if different from client’s) __________________________________

Subscriber’s birth date (if different from client’s) _______________________________

I authorize this office to release any information necessary to expedite insurance claims.  I  understand that I am responsible for all for all charges, regardless of insurance coverage.

Client, Parent, or Guardian signature ___________________________     Date ____________

PRE- INTAKE FORM- please print clearly

 Name ___________________________ DOB ____________   Age ______

 Marital status  a.Single ____    b.Married ___ what year?_____ c. Separated ____ year? ____

 Spouse (first name/age) __________________________________________________

 Children (first names/ages) ____________________________________________________

 Who is living in your present home with you? _______________________________________

 Level of Education ______________________________________

 Currently in school/training program?    (please circle one)       Yes        No   

 If yes, Where?______________________________________________________

 Employed?      No   Part Time   Full Time  

 (if no, skip to Present medical conditions)

 *If other than client, name of person employed and relationship to client:

 ________________________________________________________

 Where employed? _______________________________________________

 Employed here since when?  ________________________

 Present employment position _________________________________________

_______________________________________________________________

Previous positions (last five years) _______________________________________________________________

________________________________________________________________

 Present medical conditions (high blood pressure, diabetes, allergies, etc.)

 ________________________________________________________

 ________________________________________________________

 History of medical (non-psychiatric) hospitalization?         Yes         No

If yes, please indicate year and reason (do not count uncomplicated pregnancies)

_______________________________________________________________

Are you taking any prescription medication  now (psychiatric or otherwise)?    Yes      No

If yes, indicate Name of Medication, Dosage, Since When Taken, and any Present Side Effects:

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

Please list any additional  psychiatric medications that you have previously been on:

 ________________________________________________________________

  ________________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

Have you had any psychiatric hospitalizations?                   Yes            No 

If yes, please indicate where and approximate dates:

 ___________________________________________________________________

 ___________________________________________________________________

 ___________________________________________________________________

 ___________________________________________________________________

 Have you been in therapy before?          Yes               No

_______________________________________________________

 ________________________________________________________

 ________________________________________________________

 ________________________________________________________

 ________________________________________________________

 ________________________________________________________

 ________________________________________________________

 Thank you for your information.