Intake
Form
|
| Select Physician * |
|
|
| Name *
|
|
|
| Email |
|
|
| Address * |
|
|
| Gender |
|
|
| Phone Number * |
|
|
| Date Of Birth |
|
|
| Age |
|
|
| Relationship Status: |
|
|
| Current Living Arrangements |
|
|
| Time Living At Current
Residence
|
|
|
| Have you ever received
psychological /
counseling / psychiatric services? *
|
|
|
| If "Yes", please describe |
|
|
| Level of completed
education:
|
|
|
| Current employment
situation:
|
|
|
| Current Medications: * |
|
|
| If yes, please list name
and dosage
|
|
|
PROBLEM CHECKLIST (check
any symptoms that
apply whether problem heading is correct or not)
Depression |
|
low
frustration tolerance
crying episodes
irritability
hopelessness
sleep problems
difficulty
concentrating
memory problems
weight loss
thoughts of suicide
weight gain
withdrawing from
others
difficulty
functioning at work
overeating
difficulty
functioning socially
nausea/vomiting
low energy/fatigue
difficulty
making decisions
reduced
interest/pleasure
recurring
thoughts of death or dying
feelings
of worthlessness/guilt
|
| Anxiety |
|
agitation
panic attacks
restlessness
fear of leaving
home
excessive worry
voidance
of public places
fearfulness
avoidance
of social situations
trembling/shaking
pounding heart/palpitations/shortness of
breath
fear of loss of
control
chest pain
fear of dying
|
| Stress/Trauma |
|
Flashbacks/re-living
bad experiences
Intrusive
thoughts of bad memories
Easily
startled/upset
Nightmares
|
| Substance Abuse |
|
Excessive
use of alcohol/drugs
Fail at effort to reduce use of
alcohol/drugs
Use substances to cope with difficult
feelings/life problems
Legal problems related to substance
use
History
of substance abuse in family
Cigarette use is troublesome/causing
health problems
Memory
loss following substance use
Unconsciousness
due to substance use
Health problems/accident(s) due to
substance use
Substance use causing problems problem
with friends/family/work
|
| Eating Problems |
|
Excessive eating
Obesity
Underweight
Self-induced
vomiting
Use of laxatives
Obsessing
about food, diet, exercise
Eating problems interfering with
health
|
| Thinking Problems |
|
Seeing
things others do not see
Fearful
others are talking about you
Fearful someone is plotting against
you
|
| Attention and Behavior |
|
Difficulty completing
tasks/distractible
Taking on more tasks than can be
completed
Difficulty focusing
Frequent
forgetfulness
Tendency
to be impulsive
Difficulty
waiting your turn
Not well organized
Difficulty at work/do not stay on the
same job
Problems
with co-workers
Problems
with legal authorities
Problems
in school growing up
|
| |
|
Staying
up for days without sleep
Excessive spending
Excessive gambling
High
risk sexual behavior
Aggressive/abusive
toward others
Confused/worried about sexual
behavior
Marital conflict
Parent-child
conflict
Other family
conflicts
|
|
If you
are experiencing serious suicidal thoughts , please stop now and phone
your local suicide hotline or phone 911 or call 1-800-273-TALK (8255).
When describing your problem (below) you will help your therapist to
provide
the best possible and most relevant response, if you include the
following information:
1. Describe the problem in a very specific and understandable way.
2. How long has the problem been present? (When/How did it start?)
3. Why did you decide to seek help now, through e-therapy?
4. Who is involved/affected by the problem. Describe their
involvement.
5. What have you already done to try to solve the problem? What has
helped
(even if only a little) and what has failed to help?
6. What would the first small sign be that tells you the problem is
beginning to improve or change for the better?
*Do not use the "enter" key it will submit your form. Continue typing
and the form will format your response.
Using the suggestions/questions and problem/symptom checklist above as
a guide, please give your therapist a summary of the problem you want
help with (Use as much space as you need.
(Do not hard return using
the enter key) |
|
|
|
Now that you have described the
problem, please ask your therapist the specific question(s) you would
like answered, in relation to your problem, that will provide you with
the information you need in order to take the steps that will begin to
improve your situation.
(Use as much space as you need.
(Do not
hard return using the enter key) |
Note: This service is not intended for
individuals who are actively contemplating suicide or are suffering
from a severe mental or emotional disorder. If you are
experiencing serious suicidal thoughts, please stop now and phone your
local suicide hotline or phone 911 or call 1-800-273-TALK
(8255). This service is also not intended for use by minors [under 18
years old].
|
| Please select type of
consultation:
|
|
|
| |
